How to Determine the Best Time to Do Patient Documentation

You may wonder if this is a trick question. As a clinical physician, the best time to finish your notes is within the same day as you see the patients. When in the day? Ideally, you finish each patient note, one at a time, right after you see each patient.

It is not as straightforward of an answer. No, I am not here to complicate things. I am here to invite you to consider how different settings and different resources will affect your efficiency and productivity.

When you are considering the best time to write the patient notes, you are thinking of the optimal timing of recording your findings and formulating your management plans in the most efficient manner. After all, many physicians are experiencing burnout from the burden of patient documentation.

Let us consider the outpatient setting. For most primary care and specialty practices, there are set schedules to see the patients. Yes, you are compensated for each patient you see. If you are an employed physician, your salary is at least partially based on your productivity. If you do not see patients and bill for your services, you or your company will not be compensated. The only way to bill legitimately is to have clear documentation of the patient encounter.

Examine your schedule. Does it look realistic? For example, if you are a hematologist and oncologist, is it possible to take care of an oncology patient who is actively getting treatment for her cancer within ten minutes? It is important to see if you are overbooking your schedule. Yes, you want to be efficient and you do not want to compromise the quality of your care of the patient connection you make. Most offices schedule established patients for fifteen to twenty minutes. It is more than enough time if you are addressing only one uncomplicated medical issue. If there are multiple problems or one big problem to tackle, you probably will need more time.

Either way, for outpatient settings, it is best to complete each patient’s note before you start to see the next patient. This allows you to focus on one patient at a time, so that you can generate a treatment plan and write all the necessary orders related to that plan. When you are finished with the patient’s order and documentation, you can then put your focus on the next patient. When you can focus on one patient at a time, you think better, you remember things better. This results in more efficiency.

I have always talked about charting in the exam room. This depends on a few things. Are your exam rooms set up in a way that you are facing the computer and the patient in the same direction? Is the computer system you are using easy for you to log in and log out of several computers quickly? If it takes five minutes for the exam room’s computer to load up, it may be faster for you to write your patient note right after the encounter.

What about AI scribe? This is a popular topic lately. I am all for technology that can improve our efficiency. If you have access to any AI scribe programs, your note is completed shortly after you walk out of the exam room. The best time to review that note is before you start seeing the next patient. When you are not personally documenting the patient’s findings or plans, it is more difficult to remember all the details afterward.

So far, it seems like seeing the patient and doing the chart before moving on to the next patient is the most efficient way. This is assuming you have all the resources to support you this way. There are times when seeing the patient and doing the chart right away is not the most efficient approach.

Let me offer you my own example. Yes, in the outpatient setting where I spend most of my clinical time, seeing one patient and completing that chart before seeing the next patient is the best way to operate. However, I do not do this for the inpatient rounds. This is why.

When I do inpatient consultations, I am usually all over the hospital. I go where the patients are, which is almost everywhere in the building. When it takes several minutes for me to log into a different computer, I find it more efficient to see the patients in the same geographic location then return to the one computer I use to start the documentation. I usually see eight to ten patients before sitting down to write my notes.

Since the patients in the hospitals are there throughout the day (unless they are going for a procedure or being discharged), it is more flexible. You get to decide which patient to see first. I usually choose to see the intensive care unit and the critical care unit patients first, followed by the respiratory care unit and the oncology floor. That is not a set rule. It is best to always be flexible and ready to change your plan as needed.

If there is an inpatient AI scribe program you have access to, it is best to review each patient note right after you see the patient, or review the several patients’ notes whom you just saw from the same unit. You still want to take care of each patient’s orders, one at a time, so you do not mix up the orders for each patient.

To determine the best time to write your patient notes, besides having the general guidelines, it is best to figure out as you practice medicine in different settings. You may do things differently when you are taking care of patients admitted to the hospital rather than ambulatory patients.  Know what resources you have, including the computers, the programs, scribing tools, etc. Be flexible and be ready to experiment different ways to do things. You will then find the most efficient way that works for you. It is possible to leave work on time with your work done!