Finishing The Patient Notes Faster – Doing The Charts

In the previous blog post, I shared about the preparation work to chart more efficiently. Ready to finish your patient notes faster?

If you are a physician who is spending several hours after seeing your last patient to do patient documentation, or if you are spending countless nights and weekends to finish those notes, this is written especially for you. I was one of you not too long ago. The physical and mental burden of charting is real.

If you are that physician whom I just described, whatever you are doing is not quite working in your favor. Do not beat yourself up. Life is a journey and we go through many different things. If something does not work, do something else.

Before going into what you are doing, explore what you are thinking and question what you are thinking. What are your beliefs about charting? For example, you think that charting in the room by typing is distracting for the patient. What does this belief cost you? When you are thinking that typing in the exam room is distracting, you will avoid typing while you are evaluating the patient. You either do your best to remember what the patient is saying to you, or you take notes by writing on paper. After the patient encounter, you spend time to type the note. This is not an efficient way to document.

Another example: you believe that you have to keep the patients close to on time, according to their scheduled appointments. When you realize that you have spent extra time with the previous patient, you try to make up lost times by rushing into the next patient’s room, without finishing the previous patient’s chart. At the end of the day, when you are exhausted, mentally and physically, it will take you longer to finish the charts. You will remember less accurately about each patient.

You may say that, with artificial intelligence, a patient note is generated during the encounter, and you will not have this charting issue. Detailed discussion about AI in charting will be reserved for another time. Even with AI generated notes, you still have to review them.

As you are paying attention to what you are thinking about patient documentation, as you are questioning your beliefs about charting, be open to try different things. What if you change something and you get to be more efficient? You will not know until you try it yourself. Everyone works differently. One method that is great for a physician does not mean that it is the best method for you. If you are stuck with getting new ideas, ask for help. Let someone guide your journey. You will achieve your goal much faster than trying to figure it out on your own.

If you try something, and you give it an adequate amount of time, it does not seem to work – that is alright. Now you know what not to do. It is a lesson for you to grow. Be flexible and realize that there are many different ways to achieve the goal of finishing the patient charts. You just have to experiment and find the best method for you. If typing in the room does not work for you because you only hit the keyboard with two fingers, try something else. How about using a dictation program or a scribe?

Being efficient is about managing time in a way that is optimal for you. When you are in a patient room, be mindful of the time. It is a skill to learn to be caring and making the connection with the patient, to take care of the patient’s needs and to finish the patient documentation all in a limited time. Some patients are more complicated that others, and it is reasonable to spend more time to discuss and answer questions. It is important to keep time in mind while you are in the exam room. Pay attention to the clock. You have the power to lead the patient encounter. Ask questions and direct the discussion.

I cannot emphasize enough how important it is to stay focused. Be decisive, prioritize and do one thing at a time. Your brain is designed to only focus on one task at any given time. Complete one task then move on to the next one, while being mindful of the time. When you are focused, you are better equipped to filter distractions.

You too can be more efficient in charting. Examine what you are doing, what is working and what is not. Question your beliefs about the charting process. Be open to try new things and be flexible. If you are stuck, ask for help, so that someone can guide you. Always be mindful of your time. Stay focused and minimize distractions. You will find yourself working more efficiently.