Schedule a Consult

Finishing The Patient Notes – The Prep Work

Dec 09, 2024

β€œI just want to get my notes done.” That used to be what I said to myself every day. At that time, I was spending several hours after seeing the last patient to finish the patient charts. Oftentimes it would go into the weekends. It was out of frustration and overwhelm that the sentence became a wish that was too good to be true. Since I believed that was an impossible feat unless I stopped working full time, there was an added layer of frustration. Most of the time at work was spent in patient documentation rather than in direct patient connection.

In our coaching sessions, I always ask my physician clients why. What is the reason for wanting to finish your patient notes faster? Most of them want to spend more time with their families. That was me too. Not too long ago, the long hours I was working to finish the notes cost me the time with my family. It also cost my emotional well-being. I was easy to anger, easy to feel frustrated, always skeptical and did not have faith in myself. I was so absorbed in time requirement of writing the notes that I forgot why I wanted to finish them or why I chose medicine.

Even if you do not like doing the patient notes, they need to be completed – unless you are no longer in clinical medicine. The notes are supposed to be completed in a timely fashion for each patient’s care. You document about the patient, about the presenting illness, the history, your assessment and plan of action. This helps you take better care of the patient and better continuity of care when they come the next time. Before you go deep into how you are to finish the patient notes in a timely fashion, it is important to accept that patient documentation is part of clinical medicine. No matter how badly you wish for no notes, the charts will still have to be completed somehow.

Acceptance does not mean you have to like it. You do not have to like doing notes to be efficient in doing them. It is more helpful not to have a grudge against patient notes. The patient notes are neutral. They are just notes. What do you make them mean? Do you view them as the obstacle for you to going home on time? How does that make you feel? Or do you think doing patient notes is unnecessary? Remind yourself why there is patient documentation. What would happen if no one documents anything about a patient? How does that affect patient care? (I am not even talking about reimbursements.)

One thing that is challenging about patient documentation is not the recording aspect of it. It is the belief behind doing the patient charts. As most of us physicians were trained to be perfect, we are used to aim for perfection. It is not easy for some physicians to accept that patient notes need not be perfect. Imperfect notes do not mean you include the wrong information or you omit important information. It means that you allow unintentional spelling or grammatical mistakes. You allow the patient note not to be a novel. You allow the patient note to include only the absolute necessary information. You can develop the skill to balance between efficiency and what to include in the patient note. Even with the help of a scribe or artificial intelligence, you still want to write a concise note, so you or the other readers will not spend extra time to read information that is not helpful in patient management.

In order to do something well, it is important to be prepared. Prepare your mind will lighten the mental load of charting. First, remember why you want to get the patient charts done. Remind yourself the most important reason. Most physicians share that they want to spend more time with their families. Second, accept the reality that the patient notes need to be done in a timely fashion – not only for billing purposes, but more importantly, for better patient care. Third, change the way you think about patient documentation. Think of them as neutral and necessary rather than something you strongly dislike. Lastly, accept and allow imperfections with patient charting. Include the necessary information to remind yourself about the patient and use that information to communicate with other clinicians. With this preparatory work, you are equipped to figure out the most efficient way to do your patient charts.

Are you ready to stop feeling stressed and overwhelmed? Are you ready to have more time to do what you want?

 

Get your FREE ultimate guide to combat burnout now!

Start your journey of clarity and to be true to yourself. Don't wait to feel better!

I'm Ready!