Do you feel EMR charting is a burden? Do you struggle to complete your notes on time? If you answered yes to one of those, you’re not alone!
Doctors spend, on average, 16 minutes in their EMR for each outpatient encounter. This represents several hours of your time each week! Writing comprehensive notes is a requirement in our practice for patient care monitoring, controlling care quality, billing compliance, and legal protection. We have to deal with this task.
This post will explore a key element of medical documentation: timing.
When is the best time to write your notes?
I have observed doctors charting at many different times:
- During the encounter
- Just after the patient has left the room
- After a few other patients
- At the end of the day
- In the evening at home
- On the weekend many days later
- Never (?)
Is your approach to writing down key elements while discussing with the patient, then having to finish your note later? Are you among those who push back charting to the end of the day? Do you bring this task home?
A recent U.S. study shows that after-hours charting is significantly associated with physician burnout. 34 percent of survey respondents said they spend an impressive 6 hours or more weekly on after-work charting. And for 2 percent of them, it’s more than 25 hours a week!
So, do you chart at the right time? When is the best time for charting?
My answer is straightforward:
Start your note during the visit and always finish it up before moving on to the next patient.
The benefits of making your notes right away
Shorter time charting. You avoid interrupting your clinical reasoning when you write your note before the next patient. The quicker you make your note, the shorter the overall charting time will be. At the end of the day, you pile that up and get more free time.
More accurate documentation. If you document the encounter right away, your note is more accurate, as you limit the risk of forgetting crucial elements. And you don’t have to waste energy recalling every detail of your assessment, as the information is fresh in your mind.
Less stress. Charting right away is good for mental health, keeping you away from burnout. It will make your day smoother, as you don’t have the unnecessary stress of having another to-do in your head.
For the adventurous: Be done with your note before the patient leaves the room.
Yes, this is one step further. Every day, I finish my notes while the patients are still in front of me. It can be a challenge, but in the end, it pays off. Here is why.
You get clinical reminders from templates. Making my note during the visit helps my diagnostic process and clinical decision-making. I always use templates to start my notes, and many of them include annotations, a bunch of text displayed to me without being part of the note. With annotations, I get clinical reminders from my templates right at the moment they are needed. Clinical hints would lose their purpose if I had to wait until the patient is gone before reading them.
You limit the risk of having to call the patient back. How many times did you realize you forgot something to tell your patient while you’re finishing a note? As they’re already gone, you have to reach them, which is a waste of energy. Being done with the note while they are still in your office means I never end up calling them back for elements I didn’t come up with until I wrote the note.
To keep in mind: the eye contact. Some could argue that typing in front of patients is not good for connecting with patients. That might be partially true. Most important is to still make eye contact frequently. But you don’t have to avoid completely looking at your screen or typing on your keyboard. Especially true for millennials, their phone is like an extension of their mind. It’s natural for them to have a real conversation with someone that has the eyes fixing a screen. With older patients, I tend to keep more eye contact, so that they don’t think I’m not listening.
Ready for the change?
If you’re not completing your notes on time, you’re not enjoying medicine as much as possible. Your well-being and efficiency as a physician are at stake, and the moment you chart is a highly underestimated factor you should consider.
Writing your notes before the next patient can be a challenge, but it could be a game-changer.
Charles Tanguay is a family physician and creator of Dilato, an app to help doctors make their EMR notes quickly using templates and shortcuts.
Image credit: Shutterstock.com