8 Practical Tips to Stay On Top of Charting
Just like you, I am a very busy person. At work, I see, on average, 30-35 patients a day, four days a week (10-hour days). And I take 1 in every 4 or 5 day calls. I have a relatively busy OB practice, with deliveries and inpatient hospital rounds not counting as regular business hours. This means even if I stayed up all night to catch a baby, or to take care of a sick patient, I still have to get up in the morning to attend my regular clinic.
Additionally, I precept two physician assistants, and have at least one medical student rotating with me most of the time. So far, each medical student has done at least one research project with me, all of which have resulted in publications or presentations.
And outside of work, I try to write. On the weekends, I love to go backpacking with Moshi Moshi (my labradoodle puppy), and travel.
How much time do I spend charting at home, you ask?
Almost none.
How late do I stay behind to chart after work?
About 30 minutes (an hour if I am distracted by Twitter).
It’s safe to say that before I go home and before I come to work each day, my InBasket is almost always “0”.
And no, unfortunately, I don’t have a scribe, which has been shown to reduce burnout.
Here is a list of things I do to help me be on top of charting, stay productive, and somewhat sane.
1. Know your “panic” number, and stick to it.
How many unaddressed items can sit in your InBasket before you get stressed out? This is your “panic” number. Once you have an idea what this number is, set a goal to reduce your InBasket items to below it, before you go into the next patient’s room.
Some people feel that so long as there are patients ready to be seen, they have to keep going regardless of how many things are left undone. To me, this can “hurt” my patient care: if I have more than 10 things in my InBasket that are not addressed, each time I open my EMR and see this number in the right upper corner, I feel instantaneously stressed. And when I am stressed, I am distracted, and I am not fully present with the patient in front of me. That is not fair for anyone. So to prevent this from happening, I sit down at my desk to reduce the little number by my InBasket to below 10, before I move on.
Note, if you can tolerate a very high number before panicking, like 100 or more, first of all, check in with yourself to see if you are simply too burnt out to care; and second of all, contrary to my usual advice to patients, you might want to consider freaking out early and freaking out often.
2. With permission, type as you take history.
Almost always, I find the patient sitting on the exam table when I walk in a room. But my rooms are set up in a way that if I face the computer, I cannot see the patient on the exam table. So, I invite the patient to sit by my computer, so I can type up a note, but face the patient at the same time.
“Come and take a seat over here, so you can tell me everything about your symptoms before we do our exam” is how I phrase it. I genuinely mean it, I want to take a thorough history, and I ask my review of system questions following the logic of the symptoms, so it makes sense to type up at the same time.
Of course, I always ask if the patient minds that I type at the same time as we talk. If the patient doesn’t want me to, or I sense that it bothers them even if they say it doesn’t, I stop. Naturally, if we are talking about sensitive or emotional issues, I tend not to type but just listen. I find that patients understand how much work we do each day, and they are happy to help us reduce some burdens.
Usually by the time I leave the room to go to my desk again, I could simply put in my orders and sign the note after changing just a few things.
3. Utilize teams to address results.
In my practice, we have a “normal result” team in the EMR to whom I can send the simple and normal results to. For all the easy results that are completely normal, I send to this team, sparing my own team and myself of the busy work to call. If your practice doesn’t have something like this, and you think it might be helpful, you can propose for a change.
4. DON’T ORDER THAT MANY LABS/TESTS
Physicians have diagnosed ailments and medical conditions long before there were the “shot-gun approach” of data blasting. This is what I tell the new colleagues I precept: rely on your clinical judgement more than the numbers, treat the person, not the numbers. This sounds cliché, yet it is not only true, but helps reduce InBasket burdens. Because when the lab results accumulate in your InBasket, they generate more work for you.
For new providers, this can be scary. How do we know for sure what the patients have, if we don’t specifically test for things? The problem is, for most things people come to the primary care doctors’ office for, there are usually multiple differential diagnoses. List them in your notes by probability with the most common things first, and limit your tests to those. Often, you will find, after a thorough history and exam plus shared decision making with your patients, you might not even need any tests before you feel comfortably enough to treat the patient for your top differential. And when you follow up with the patient, if the treatment didn’t work, you go down the list together.
Sometimes, patients come in requesting labs and X-rays. Don’t be afraid to actively talk them out of it if you feel that they don’t need it. Explain to people why more data isn’t always better data, and why sometimes getting numbers that are uncertain or confusing can cause more harm than good.
Remember, you are a clinician before you are a data analyst. They are always coming up with newer and fancier tests, but none replaces your clinical judgement.
5. Clean up your InBasket before you go home.
If you follow my #1 advice, by the end of the day, you probably don’t have more than your panic number of things left to address. And if you follow my #2 advice, this number includes the unfinished notes of the day. So, use the same panic number principle for being fully present for patient care, and apply it to home life. Ask yourself, if I go home now without reducing the items down, would I stress about this when I get home? Can I enjoy a family dinner without thinking about work?
At this point of my career, my answer is no. So I stay and finish my stuff. And if I focus, I can do it in 30 minutes or less. So by the time I get home, I can eat dinner and relax like a normal human being.
6. Clean up your InBasket before you go to work.
In the morning before I go to work, while drinking my morning coffee, I do another “house cleaning” of my InBasket. Sometimes results would come back over night, or there was that one last note I just couldn’t bring myself to do before I went home yesterday. I like my InBasket number to be 0 before I show up to work, this is how I feel ready to brace a new (crazy) day.
7. Address complicated results yourself. And don’t be afraid to bring patients back to have a face-to-face conversation.
I am a big fan of follow-up visits. I love to see patients again, and I hope they love to see me again, too. This is especially a good practice if a result will likely generate more questions and more phone notes to address. Don’t kick the ball back and forth and have your team call patients just so they can ask you a question in another phone note. Call the patient yourself, or ask your team to help the patient make an appointment so you can talk in person. This way, you can sign off the results, and use scheduled clinic time to talk to patients.
It’s also a good practice to put in your own orders. Don’t shout your orders at your team for them to put in: it creates more errors, and it increases the possibility of that “shot gun approach” mentioned above.
8. Teach your medical student to take a good history.
Medical students are amazing. Depends on the situation, they might not be able to write a note for you. In my rural primary care practice, I give our medical students a lot of clinical hands-on experience. They have come a long way to work with a country doctor, the least I can do is to NOT have them just shadow. Most of them take history, and trust me, once they are allowed to spend time with patients, and learned systemically review of system questions, they do an amazing job.
I always ask the student to present the history (and exam, sometimes assessment and plan, depending on their level of training) to me in front of the patient if appropriate. And I always give them time to prepare, this way, they can give me a presentation that they are proud of. When they do, I type the note up. As their history taking skills improve (usually rapidly), their presentation becomes a beautiful note.
I find that patients love to watch us teach medical students. They love to see the “behind the scene” reasoning being spelled out in front of them in form of teaching. And who knows, you might inspire a patient to go into medicine, too!
Lastly, don’t forget to do the things that refuel your soul. Read that book on your shelf, listen to that podcast, hike that trail, take that vacation. Work doesn’t love you back, people do. And when you come back refreshed, they love you more for it.
Of course, not all of the above tips are useful for all. For instance, I don’t use dictations. I used to in residency, when I mostly did inpatient work, and typing while rounding was not feasible. Dictations are awesome, and it forces you to get things done because you have to think fast as you are talking, this is especially beneficial if you are a slow or distracted typist.
Recent data show that women physicians spend more time in the EMR, and on writing notes. And it is a well established fact that women physicians spend more time with patients in the exam rooms, on the phone with patients, and interacting with nursing staff. To me, this doesn’t say female providers are slower. Rather, it says we are more generous with our time. So as a female doctor myself, I am fully aware of how much of my life medicine is consuming, especially since I chose to become a country doctor. Being on top of charting is one of the ways I help myself to not burnout so fast.
