THE LAST WORD
Getting Your Notes Done on Time
These seven tips can help you spend less time on charting.
Fam Pract Manag. 2016 Mar-Apr;23(2):40.
Author disclosure: no relevant financial affiliations disclosed.
In the age of paper charts, physicians' notes were as quick to produce as their scribbled handwriting, and just as legible. Now that we have electronic health records (EHRs) and documentation guidelines, many physicians struggle to complete their notes in a timely manner.
Here are some charting tips (for those of us without scribes or dictation systems) that I've gleaned from years of practicing medicine and coaching residents and fellows.
1. Leverage the skills of your team members. You don't have to document everything yourself. For example, the medical assistant or nurse on your team can document the patient's concerns, review medications, and verify or document allergies. You can then quickly review the information for accuracy and sign off on the note.
2. Get done what you can in the room. When talking with a patient about his or her history or treatment plan, make notes as you go, summarizing aloud to engage the patient and ensure understanding. You can even complete electronic prescriptions in the exam room so the patient knows they have been sent and you don't have that work waiting for later.
3. Know the E/M documentation guidelines. A 99213 level of service does not require a comprehensive review of systems or a comprehensive exam. Document what's medically necessary and complete for today's visit, and no more. (For more information, see the FPM Documentation Guidelines topic collection.)
4. Use your basic EHR functions. Templates and the copy and paste functions are helpful for routine visits where clinical queries are standard, but use them judiciously. “Today's note” should accurately reflect the patient's condition today and your impression today, so make sure to modify any templates or copied material to reflect this. In complex or changing situations, it may be faster and more accurate to avoid such features. But if it's flu season and you don't have a functioning influenza vaccine template, take 90 seconds to create one, and save yourself time down the road. In ad
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