In recent posts, we have been talking about physician burnout. We looked at the current state of burnout, what’s being done to tackle burnout on the national stage, and the financial argument for dealing with burnout.
We also explored the leading cause of burnout: charting.
Now I want to shift my attention and start a series of posts providing tips to help you with your charting, especially if you spend any time in an outpatient setting.
This post will look at one of the biggest game changers for me: charting at you go.
Let’s get to it!
Don't Stop Me Now
Charting as you go means by the time you finish seeing or immediately after seeing a patient, you complete all the work related to that visit. This means the note, orders for testing and referrals, visit diagnoses, messages to other staff, billing codes, and any other tasks required are completed. All of them.
I know what you’re going to say. “But I’m already behind” or “the next patient is roomed and waiting.”
Both of those statements might be true. But it still doesn’t matter.
Ten-Hut!
Every patient you see deserves your full attention. By not charting as you go, you are not giving your full attention.
Instead, you are choosing to split your attention x number of ways, where x is the number of patients you’ve seen up until this point.
All the prior encounters’ incomplete tasks sit in the back of your mind and occupy a small portion of your mental bandwidth.
Your brain does this because it does not want to forget these tasks. They’re important and need to be addressed.
However, this creates mental drag, not unlike a ship picking up evermore barnacles that decrease its hydrodynamics.
You find a GIF of barnacles on a ship…
Thus, not only are you functioning slower mentally, but you’re also failing to be truly fully present with patient in front of you. And that’s a disservice to that patient.
Stop Punching Yourself in the Face
Additionally, you’re making your work day harder for yourself.
You’re setting yourself up for more interruptions throughout the day—patients calling wondering where their meds are, lab calling you for the orders you forgot to put in for the patient waiting in lab, etc.
Every interruption slows you down more and disrupts your rhythm.
As you mentally juggle all the tasks that need to be done later, a sense of dread starts building. You want to complete the work but also want to get home to enjoy your free time, however you may spend it.
(I don’t want to know how you spend it—no, really).
By the end of the day, the 2-4 minutes of charting each encounter needed has now ballooned to 5-10 minutes because:
- your brain is literally fatigued from making hundreds, if not thousands, of decisions, and
- you have to spool up your hard drive to remember what occurred during each encounter (to document) or what needs to be done (to place orders).
If You Won't Do It For Yourself...
With your orders and referrals placed by the time they leave, patients are able to more expediently pick up the medications you prescribed, complete necessary labs, or set up referrals, which is a huge satisfier.
I’m not going out too far on a limb to state increasing convenience increases adherence and completion/uptake rates.
As you can see, charting as you go can help you provide superior patient care and, thus, I would suspect also improve outcomes!
One of These Things Is Not Like the Other
Let’s look at how waiting to chart versus charting as you go plays out comparing two scenarios.
In both scenarios…
- 20 patients to see, 10 per half day (typical for primary care)
- 1-hour break for lunch in between each half day
- Scheduled to finish last appointment at 5pm
- First patient shows up 10 minutes late
Scenario 1: Status Quo — Waiting to Chart Until the End of the Day
- Great, the first patient is late. You spend the first 2-3 minutes panicking about how that’s going to ruin at least your morning and peruse your morning schedule wondering where you’ll find your reprieve.
- Then you chart prep for Pt #1 and knock out five result messages before they’re ready to be seen.
- You come out of Pt #1’s encounter and you’re 15 minutes behind. Instead of spending a few minutes completing the charting you go straight to Pt #2 who is roomed and ready to be seen.
- You place med refills for Pt #2 during the visit, but at the end she asks, “You did send in the brand name medication, right? The generic just doesn’t work for me.” You know you sent in the generic and tell her you’ll be sure to resend the brand name when you get back to your work area.
The brand name version does this!
- Of course, Pt #3 is ready so you go straight to see them and forget about resending the prescription.
- You keep slogging away, but you’re 25 minutes behind now, apologizing to every subsequent patient for the delay.
- You get to Pt #7 who comes in with a simple UTI. You make up some time here and finish their charting. However, you still have not completed charting on Pts #1-6.
- You start with Pt #8 and realize the acute issue for which they came in is not the main issue—their anxiety is. They are tearful and you realize this is going to be a long visit. Halfway through, there’s a knock on the door. You excuse yourself and offer Pt #8 some Kleenex as you leave awkwardly in the middle of a sensitive conversation.
- Your assistant has pulled you out because Pt #2 is waiting at her pharmacy angry that you sent the generic and not the brand name prescription like you said you would. She now wants to talk to you, and only you.
- You take the call and 5 minutes later have finally mollified Pt #2 and resent in the brand name prescription.
- You return to Pt #8 who seems sullen and more subdued. You apologize for the interruption and try to pick up where you left off, but Pt #8 is not having it. Argh, you were so close to connecting the dots for them about anxiety! Instead, you agree to run some labs and have them follow up in two weeks.
- You’re now 40 minutes behind with two patients left before lunch. Hah, lunch. That’s gone out the window.
- You finish the last two morning patients by 12:30pm. You have nine notes to finish and you haven’t touched your inbasket since first thing this morning. You look at your calls and see there is a specialist you need to call back. You realize this is the only opportunity you have to call them, so you do.
- It is now 12:45pm and you grab your lunch and take one bite then try to hammer through some other calls and messages. You still have 9/10 notes left from this morning…
Phew, just typing that was exhausting!
- The afternoon half day goes pretty well but you only complete two of your notes as you go. You finish seeing patients by 5:15pm.
- You just finished your “work day” and still have 9 + 8 = 17 notes left as well as inbasket work.
- You realize you didn’t get to eat more than one bite of lunch so poke around at your cold food. You also want to catch up on social media before you tackle some work before going home.
- Ahh stupid social media vortex! It’s 5:30pm and you’ve touched nothing!
- Now you start hammering through your inbasket and address the more urgent things as well as refill requests. You did realize you have to call one patient back for a timely issue. Your assistant could have easily handled this during the day but they needed your input which you didn’t have a chance to provide, and so it falls to you at the end of the day.
- You close out five more charts but it’s 6:30pm and you just want to go home.
- You leave with 12 charts left to complete.
- You know you’ll be working on notes after dinner and the kiddos’ bedtimes.
- Late at night, after spending 1.5 hours charting, you still have two charts left but you’ve been moving ever more slowly and you’re exhausted. You grab a glass of wine and…
Now add the layer of complexity that COVID brings with less support staff, more calls and messages (patients not wanting to come in as well as wanting to know how they can be moved up in line to get vaccinated), and more time to don/doff appropriate PPE. No wonder this burns us out!
Scenario 2: Charting as You Go
- You crush your day and it’s all rainbow and daisies!
Okay, just kidding…but only sort of.
- Again, Pt #1 is late. You finish seeing them 15 minutes behind. You wrote up the subjective and placed orders as you went along. You now take 3 minutes and close that encounter.
- You start with Pt #2 18 minutes late. You send in the generic med and later find out she wants the brand name. Before you leave, you send in the brand name medication for her. After she leaves, you finish the note and close the chart.
- You’re 30 minutes behind (5 minutes worse than scenario 1 in terms of seeing the next patient) and keep slogging away and closing charts as you go.
- You get to Pt #7, the simple UTI, and close that chart before they even leave the room. You are all caught up with charting at this point and now only 20 minutes behind.
Take that, charting!
- You scan your calls quickly and see that you need to call a specialist and that there is also a time sensitive patient concern that can be easily addressed. You give your input on this latter call and route it back to your assistant. She is able to take care of it before she leaves (so you don’t have to at 5:30pm like in scenario 1). You make a mental note to call the specialist during lunch.
- You go in with Pt #8 but this time you’re not interrupted for the call from an angry Pt #2. You finish that visit having put in the time but more satisfied as you were able to bring the patient around to seeing this was anxiety at play. You don’t need to run lab tests but you refer them to psychotherapy and have them follow up in 4 weeks. You don’t actually type in the room given the patient’s state so you do have to complete this chart still.
- You are still 30 minutes behind with one chart to close. You go and see your remaining two patients and finish up by 12:25pm with their charts closed.
- You remember you need to call the specialist so do so and finish Pt #8’s chart while waiting to connect with them on the phone.
- It is now 12:40pm and you’re done with all your morning charts and important calls. You grab and eat your lunch while signing refill requests and addressing a few lab results.
- Your afternoon half day goes pretty well and you close all the charts as you go, ending by 5:05pm. Yes, all charts are done shortly after the last patient leaves AND you finished 10 minutes earlier than in scenario 1!
- You were able to eat lunch and you know you’ll have time to check your social media later, so you clean up your inbasket by 5:30pm and then head home without any work left. Amazing!
- You enjoy dinner and time at home with the kiddos knowing your evening is yours to spend as you choose, free of your EHR!
What Kind of Sorcery Is This!?
The feel-good kind? Okay, yeah, that was too hokey, sorry.
I know you’re thinking, “Yeah, but you just made all of that up so…it’s fantasy!”
But here are a few takeaways and tips on which you should focus instead:
- Putting time in during and after every visit to complete all the orders and notes allows you to close each chart and be done with that encounter mentally. You move on unencumbered by lingering thoughts of what you need to recall.
- This involves writing your note while you’re seeing the patient, which is a skill to learn. I’ve become quite adept at asking one question while I’m typing something else.
- Your note doesn’t have to be a work of art. Settle for less than stellar prose or even bullet points.
- I didn’t mention this above, but by charting as you go, you increase the likelihood you document those abnormal physical exam findings like a murmur since the time between exam and note are drastically reduced and your recall is better. Also, you’re not trying to remember who the hell had the murmur at the end of the day!
- Notice how you finished the afternoon faster in scenario 2? It’s because your mind was nimbler (and nourished/not hangry thanks to lunch!)
- You actually create LESS work for yourself because everything’s addressed before the patient leaves, which means fewer interruptions later. See how that paid off dividends later?
- You also were able to delegate a task that your staff could handle versus having to deal with it on your own at the end of the day.
Charting as you go can help you become a boss at getting your work done!
I hope I made the case for and convinced you that charting as you go is the way…to go! It has revolutionized my relationship with work; coming home without work tugging at the corners of my mind has been a huge satisfier and reducer of burnout. When I watch Netflix at night, I’m not buffering to avoid charting, I’m just enjoying Netflix in peace!
I’d love to hear your thoughts—did you find anything particularly helpful? Let me know in the comments section below.
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