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In this post, I pull back the curtain to share with you some of the most potent logistical considerations that help me chart as I go and leave my work at work.
Should I Chart As I Go?
“If I go there will be trouble / And if I stay it will be double.”
I’m fairly certain The Clash were not referencing charting in their hit song, but I won’t assume anything.
The short answer to this question is: YES.
The long answer can be found in these posts:
- Charting as You Go
- Your Charting Mindset
- The 9 Reasons You’re Slower Charting at Home
- How to Crush Charting if You Do Bring It Home
- Why I Started Charting as I Go
- My Top 3 Internal Barriers to Charting as I Go
- The 4 Strategies I Tried Before Charting as I Go
(You may have noticed it’s a popular topic.)
By now you’re hopefully on board with the idea. But maybe you struggle with executing it?
In this post I want to go over some of the logistics involved with charting as you go, how it looks in my practice, and any tips/tricks I can offer.
What we’ll cover:
- typing as you talk
- leading the visit
- precharting
- agenda setting
- physical setup of your exam room
Typing As You Talk
I keep telling you to chart as you go during the visit so that you can close your encounters before seeing your subsequent patients.
If you have a scribe, then you don’t need to learn this skill (but you still need to work with your scribe to close your charts after every visit!).
If you don’t have a scribe, that means that you must type during the visit.
This may be anathema to you, as it was to me when I first started out in practice. But burning out and leaving medicine was more anathema (anathemier?) to me.
I knew I didn’t just want to have my face buried in the computer so I figured out that to do this well I’d have to master some skills.
The first is touch typing, meaning keeping your eight fingers on the ASDF and JKL; keys and typing without looking. Yes, this skill is invaluable.
The average touch typer can type 40-60 words per minute. A typical hunt and peck typer (using hopefully two, sometimes just one finger(s)) averages 25-35 words per minute.
I just tested my typing speed and it came out as 82 words per minute with a 97% accuracy. This helps me fly through notes. Moreover, I can spend more time looking at my patients instead of the screen or keyboard.
I benefited from typing classes starting in grade school and growing up with computers. Many physicians did not have this luxury and now rely on their hunting and pecking.
If you are in the latter position, painful as it may seem, I’d suggest taking a touch typing course. You can gain basic proficiency pretty fast, honestly.
The second, and harder, skill is learning to type something while asking something else. This can be a real brain twister and takes a lot of practice.
I’d say it took me about six months before I became adept enough at this. It was slogging through rote practice day in and day out.
I still make errors from time to time, but the tradeoffs of time saved and being more present for my patients hugely favor continuing this practice.
The third and final skill is active listening. Active listening is basically showing attentiveness to what is being said using short reflections and summaries, paraphrasing, non-verbal cues like nodding, and verbal cues of understanding like “uh-huh” and “hmm” (these are called non-lexical backchannels because they have no meaning but verbalize a listener’s attention).
(If you rolled your eyes at that last skill, then you’ve mastered a non-verbal cue….)
Three tips I have for making typing during the visit successful:
1) Flexible note templates that you know inside out. The templates can help me get through common chief complaints and since I know them well, I can navigate them without looking, allowing me to rapidly capture the information I need succinctly.
2) Learn keyboard shortcuts around the EHR. Knowing these means I don’t have to take my hands off the keyboard to find the mouse and stop looking at the patient to navigate to a different section of the chart. This one is easy and a huge time saver.
3) Tell patients what you’re going to be doing the first time you meet them. Part of my intro spiel to new patients is that I type during the visit so that I can capture more of what they say in their words and also make sure everything we talk about gets ordered so nothing gets missed.
I find in our digital era the overwhelming majority of patients don’t mind that I’m typing.
Leading the Visit
Leading the visit is all about leading the witness. Maybe leading the visitness?
No, I’m not suggesting that we ask questions in a way that puts answers in the mouths of our patients.
Or am I?
But we do need to help the patient navigate the visit. Think of it like a dance: one leads and one follows. Otherwise both trip, fall, and inevitably one has an “oh, by the way!”
I don’t mean to sound paternalistic. The issue is that caring for someone within a clinic setting in this day and age is so artificially constrained by the demands of the system.
I’m referring to the 20 minute appointments (some of you only have 10), all the boxes we have to check to ensure our care is “good” or “high value,” and the fact that our reimbursement is almost exclusively tied to the patient being directly in front of us.
It’s all made-up and damn confusing. That’s why it’s imperative we help lead the patient through it.
You may think it’s a frustrating waste of your energy and mental bandwidth to have to do this—and you’re absolutely correct.
Unfortunately, it’s necessary for us and our patients surviving the current healthcare landscape, and therefore incumbent upon us to do so.
So pray tell, how do you do this? You direct the conversation and interrupt to get back on track when necessary.
In aerial navigation, there’s something called the 1 in 60 rule (of thumb). It states that if a pilot is one degree off course, then they’ll miss their destination by one mile for every 60 miles flown.
The average commercial airliner flies at 550mph, so that 60 miles is covered pretty quickly—in 6.5 minutes, to be exact.
No big whoop if you catch the error immediately and get back on course. But if you don’t course correct until much later, then you could be way off course and far from your destination.
Same holds true for your clinic visits. So steer the visit back to the topics at hand before you end up weighing in on which scent of candle they should purchase next.
The next two items help you lead the visit.
Precharting
Precharting is taking time to get organized before you go to see a patient. This helps you maximize time with the patient and provide the best value to them.
Precharting can look very different for different physicians and specialities. For me, it involves four main things.
1) Starting your note. Copy forward your last note if appropriate. Or use a note template if you can.
2) Reviewing the chart. Look for high yield information like recent labs/tests and specialist visits and copy/type it/reference it in your note, whatever is appropriate.
3) Place orders. If it’s for a physical, you generally know what you’ll be ordering even if it involves managing chronic conditions. If it’s an acute visit, you can even consider what you may order for imaging/labs based on what little you know. It’s easier to place orders when someone isn’t staring at you and you’re worried about filling the silence.
“You said something about fava beans?”
Agenda Setting
Y’all know I like me some Parkinson’s Law, and agenda setting is ALL about Parkinson’s Law.
Agenda setting is all about directing and constraining the brief time we have with the patient so we can get through the health issues that need to be addressed.
Remember leading the visit? You’re placing guardrails to help guide the encounter to be fruitful and valuable.
You first have to accept that you cannot get through a long list of issues without compromising something: the attention (or lack thereof) some of those issues get, the attention (or lack thereof) your next patient gets, etc.
I consider agenda setting a team effort.
Your rooming staff can ask the patient to write down their reasons for visit and, importantly, to rank them.
This forces the patient to prioritize what’s most important to them. Then you can come in and have a starting point for setting expectations for the visit.
How you and your patient feel after agenda setting.
Pro tip: even if your rooming staff already asked them, be sure to ask again if there’s anything else they are concerned about. Get it all written down somewhere and do it at the beginning of the visit so everyone’s on the same page.
Then you can assure the patient that you want to give each issue the time and attention it deserves and that it will likely take several visits. Moreover, highlight that that’s okay because you’ve noted them and can reference them at subsequent visits so they don’t have to remember them!
This can seriously decrease the “oh, by the ways” and reassure patients that you will address their concerns even if over several visits.
Physical Setup of Your Exam Room
Lastly, I want to mention a few considerations about your physical environment with the patient: your exam room.
Remember to always position yourself towards your patient even if you’re typing as you talk. Your back should NOT be towards them.
Ideally, your mouse hand would be farthest from the patient so that there’s no physical barrier of your arm between the two of you. This is not possible for me the way our exam room fixtures are configured and may not be for you either.
I actually purchased my own keyboards and mice and tried to find the most silent ones so distractions from the sounds of my typing and clicking are minimized.
I prefer computer screens attached on boom arms that can swivel so I can easily turn the screen to show patients images and such. Even better is if there’s an additional monitor situated behind you on which you can mirror your screen to share anything relevant with the patient.
The more screens, the better!
Having a printer available in all of your exam rooms is also tremendously useful for printing off after-visit papers, paper prescriptions, etc.
These are just some ideas for how your physical setup can facilitate charting as you go.
I may do an entire post on the design of a (more) perfect exam room as it is something I’ve pondered.
Go On & Git Charting (As You Go)
Well, there you have it: some of the strategies I use to help me chart as I go.
If charting as you go is something you’ve been wanting to implement or have tried before with limited success, it may be that you just needed to apply some of the ideas presented here.
I truly hope these help and I hope you try charting as you go moving forward!
Have you implemented any of these techniques and tips to help you get your charting done? Care to share other strategies? Let me know in the comments section below.
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