The key is to dictate your notes before you leave the exam room.
Fam Pract Manag. 2005 Jan;12(1):55-56.
One simple change in your practice can improve the quality of care that you give your patients, increase patient satisfaction, protect you from malpractice claims and improve your spirits – and it costs nothing in time or money. Sound too good to be true? That’s what I used to think too.
Most physicians, even many with electronic medical records (EMR), dictate their patient charts. The standard practice is to scribble cryptic notes on a piece of paper during the patient encounter for later dictation. This is the method I followed for years. Sometimes I could decipher my notes; sometimes I couldn’t. Sometimes I couldn’t even find my notes. Often I would see several patients with the same problem but couldn’t remember the differences between them. Although I tried dictating between patient visits, I was often interrupted or got behind and would have to postpone dictation until the end of the morning or the end of the afternoon. The prospect of dictating that stack of charts caused me irritation, bordering on despair.
Six years ago, I changed all of that, and it has been the single most important change I have made in my practice. I still take the history, conduct the physical exam and review lab test results with the patient. The patient and I still discuss the potential diagnoses, the recommended treatment plan, further testing and future visits. The only difference is that I now dictate my SOAP (subjective, objective, assessment and plan) note at the end of the visit, while I am sitting in the exam room with the patient.
10 reasons to try it
Dictating in the presence of the patient provides many advantages:
1. It takes no extra time. I have to do the dictation anyway, so why not get it over with? Dictating in front of the patient takes only one or two minutes, so it does not add significantly to the length of the visit; however, it does allow me to spend a little more time with my patient, which improves patient satisfaction.
2. It costs nothing. Dictating in the presence of my patients does not cost my practice anything extra, and it does not reduce the number of patients I can see each day. It only improves my practice.
3. My history and physical exam are more accurate and complete. It is not unusual for me to have a brainstorm in the middle of dictation, and I will stop to ask the patient an additional question or check something on the physical exam. Thus, my history and physical are more complete and accurate, which can save time and decrease misadventures.
4. My patients know I have heard their story. Before dictating the subjective part of my SOAP note, I always tell patients, “Stop me if I get the story wrong.” They hear me dictate what I heard them say, and they can correct it if necessary. It eliminates the complaint that “My doctor doesn’t listen to me.”
5. My patients know what I found on the exam. When my patients hear the objective part of my SOAP note, there is no mystery about what I checked, what I found or how thorough my exam was. They hear again about the lab test and X-ray results as well.
6. My patients know exactly what I am thinking. I don’t hesitate to dictate about my patients’ emotional states, their psychiatric diagnoses, the possibility of cancer or the possibility that their complaints may not have a physical cause. They usually come into the office wondering about these possibilities, and we address them openly. Hearing my assessment comes as no surprise to them. No patient has ever voiced offense or seemed upset by this honesty. Instead, they appreciate knowing what I am thinking.
7. It reiterates my plan and instructions. Although we discuss our plans and instructions with our patients, we often wonder if they really hear us. Dictating my plan in their presence gives my patients an opportunity to hear again what we will do next.
8. It “immunizes” the chart against disputes. The last phrase on my dictation is, “Dictated in the presence of the patient.” It would be difficult for a plaintiff’s attorney to claim that I never told something to the patient when I have documented exactly what I told the patient and the patient was present when I documented it. This could be powerful protection in a dispute.
9. It changes the dynamic of the visit. Physicians are sometimes criticized for being too paternalistic. By involving my patients in the recording of the visit, I show them that I am being completely honest with them, and they become more active participants in their care. Our relationship feels more like a partnership, and they are more likely to follow through with the care plan and to get better.
10. It improves the quality of my dictation. My dictation has changed from a documentation procedure to a patient education activity. As a result, I strive to make my chart notes more organized and less filled with jargon, since I want the patient to understand what I am dictating. Perhaps my notes look a little less sophisticated, but they are clear and understandable to patients and other health professionals alike.
I have dictated chart notes in the presence of my patients for over six years now, and the results have been satisfying. Patients often are surprised to hear me dictate our visit and wonder if other doctors dictate chart notes also, but no patient has ever objected to being part of this process. Perhaps best of all, when I walk out of the exam room after seeing my last patient for the day, my work is done.
This approach could also work with an EMR system. The physician could “dictate” the visit while inputting the data directly into the EMR, with the patient still present. The physician could even print a copy of the office note for the patient to take home as a reminder of what was discussed.
Try dictating in front of your patients. Both you and your patients will benefit.
Dr. Flaherty is a family physician with the student health service and WWAMI Medical Program, Montana State University-Bozeman. He is also a clinical assistant professor in the Department of Family Medicine, University of Washington.
Conflicts of interest: none reported.
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