How can you balance documentation with a heavy workload?

Physicians can balance documentation and heavy workloads by leveraging efficient EHR (electronic health records) systems, delegating relevant tasks/reports to support staff, and using time management principles. Prioritizing essential information, using templates, and streamlining processes ensure accurate records without compromising patient care. In our acute and emergency medical facilities and clinics, we created many systems, templates, verbal dictation & screen-sharing capabilities which improved the physician time with patients where he/she really should be! Reach out for more information!

I template the heck out of what I can. The HPI is unique. The physical exam, ROS are not. The risks are templated. The discussion is not. With templating, a long narrative can be created with customization of that narrative easier than starting from scratch.

I create a template for my ROS and my physical exam section. I also create templates for my plan for common medical problems that I see, e.g. for DM or DKA, CHF, chest pain or ACS rule out, pancreatitis, and HTN. With templates, I'm not wasting time retyping things that I do repeatedly. For the HPI, which tends to be the most unique part of my documentation, a template that already has the patient's age, sex and "history of" already pre-loaded is another major time saver.

This doesn’t make sense Is work load not a part of documentation I should have priorities and time for the unexpected events Deadline for completion should include 1-2 days in advance of completion

Try to use macros as much as possible for charting. Set up your voice recognition to be able to recognize consultant names and other unique words used at your institution.

Documentation is the only proof of you have given your inputs Inputs must be in simple order as most who are following orders are nurses Legibility can never be underscored. Time is a very expensive resource for a busy doctor. Hence guidelines planned for a specific illnesses can be used for common illnesses Referrals to other specialists must be highlighted and followed physician who is taking the charge should consolidate all the inputs and clearly plan the management Duplication drug drug interactions and side effects can be definitively be highlighted so as to reduce the preventable complications. A multidisciplinary approach is a safe way of treating complex disorders and treatment approaches are personalised rather than general

It's a balance. You need to become master of new tech, not it's slave. With EHRs mastering Dragon, Templates, shortcuts and using as much preplanning is key. I spent a few months getting everything set in EPIC and can book complex surgeries in a few minutes.

If one is smart enough to become a doc, then, one is smart enough at problem solving. There is no one solution. There are many possible solutions and many individuals whom one can consult with in an informal way. I remember that in the EHR that I was confronted with, that would not accept dictation, that at colleague informed me that thru trial and error, he found an old version of Dragon that the EHR would accept, and it worked like a champ. This is but one way that I increased my level and quality of documentation including a robust paragraph on "medical necessity", and I also saved my fingers in the process. Obstacles lead one to solutions.

Invest in good EHR/EMR. A terrible or clunky EMR can add hours of wasted (and frustrating) time to your day. A key feature to look for in any EMR that physicians sign up for is flexibility or customization. There's nothing more frustrating than an EMR that was designed in a fixed (and typically backward) way, especially without physician input.

The HPI and discussion are as close to prose as it gets. The rest is mostly padding. The impression, discussion and plan are most of what other specialists see. I make those detailed and curated to the patient.

Documentation is part of providing excellent care. Good documentation not only documents what was done, but, when appropriate, why it was done, as this helps the incoming physician know the next step in medical care. In the age of "copy forward," physicians have to be careful not to write useless notes that contain outdated information from prior visits or encounters. The day's note should reflect what was done that day, in order to be efficient and effective communication of care to other members of the healthcare team. New laws now allow patients direct access to notes, so doctors need to be mindful of what things they document. Certain things do not belong in a patient's medical record, e.g. your non-medical opinions about patients.

Teamwork makes the drea work. I use APPs and my medical assistants judiciously. They know their roles, I know mine. We work together to a common goal. I am not their boss. They work with me, not for me.

I always try to make a friend in the IT department. There are so many tricks that can be taught me, work arounds, etc. It only takes for me to slow down a bit to have lunch with my new friend, and remember to bring a pen and paper with me to take notes. Let me add something perhaps silly. In my rush to finish a chart, I have a tendency not to proof read what I typed. Big mistake. When that chart is closed, it is closed. It contains errors, oversights, poor grammar, etc. This can hang me at a later date. Much better to spend a moment to polish it up.

It’s important to consider retrospective review as well. Reach out to the coding experts for input on the clinical documentation requirements. It’s important to understand how these have changed to place more reliance on medical decision making as opposed to checking boxes to ensure various elements of a specific code are met. Partnering with your administrative teams can assist in optimizing your clinical documentation and save you time.

I’m on a mission to sweep away documentation generation as the primary function of software used by clinicians. Rather the application should be a means of communication between patient and clinician, with documentation generated incidentally as the process of bilateral information gathering and sharing occurs.

The documentation of the encounter is my least favorite part of medical practice. For physicians like me, we have to find ways to make documentation less burdensome, such as using dictation/dragon or having a scribe, but these are expensive. It would be great if hospitals, government, and employers can invest in technology or staff that perform this aspect of a physician's job in real time, while the doctor is seeing the patient. I know that would make me happier about medical practice, and I would be able to see more patients. It would reduce or eliminate the time spent "after work hours" finishing up patient notes, which would significantly improve physician's quality of life and limit burnout.

“There is nothing so useless as doing efficiently that which should not be done at all” – Peter Drucker. From my experience working in different hospitals and in different departments I can conclude that a lot of what is being documented is rarely used or even usable. The feedback of nurses and doctors to improve the medical records is rarely implemented.