Ideal patient schedule

[mpbrooks77]

I am now going on my 4th year at a family practice office.  Initially I saw a lot of pediatric patients and could see 20-23 in a day and only need to stay about 30-45 mins after work hours (8-5) to finish charting.  My patient population was probably 75%/25% - peds/adults.  We've had a lot of PA/NP position changes and now my population is more 55%-45% - peds/adults.  I also have a new baby, so I have to be out of the office by 5:15 to get him from day care.  I now see between 18-22 pts a day and probably chart 1-2 hours at home once the family's asleep.  It's been 7 months and it's starting to wear on me.  Luckily my office will change my schedule  so that I can hopefully have less charting to do at home.   Patients are usually scheduled from 8am - 11am, closed for lunch from 12pm - 1pm, afternoon patients from 1pm - 4pm, office closes at 5pm.  So I was thinking if I saw 4 check ups every 30 mins  for the first 2 hrs and then acute patients every 15 mins afterwards until 11 am, then again after lunch the same thing, then I should be able to catch up on my charting and hopefully have no more than 30 mins of charting at home.  I usually only take 15 mins at lunch to go grab something to eat from the hospital and take it back to my desk to work and eat.  The key is for the front desk not to squeeze patients in between my check ups or to double book me, which they've been known to do.  

 

For those in family practice or internal medicine, what kind of patient schedule has worked for you?  Or what would your ideal patient schedule be?  Has anyone done 20 min appts?  What do you think about them?

 

 

[mainah]

For those in family practice or internal medicine, what kind of patient schedule has worked for you?  Or what would your ideal patient schedule be?  Has anyone done 20 min appts?  What do you think about them?

I'm going into my 3rd year of rural family practice at an FQHC. I see mostly adults/geriatrics as our practice has maybe 30 peds patients. We get 20 mins for routine f/u and acute visits, 30 mins for procedures, and 40 mins for physicals/medicare wellness visits/well child checks. Office is open 8-5, I get an hour for lunch, and an hour in the morning and 30 mins at the end of the day for admin time. Except my admin time is usually filled with walkins as we can't turn them away and we have a pretty high tourist population. I can see up to 16-18 pts/day with a schedule layout like that.

 

I'm really struggling with keeping up with the charting. I'm at the office essentially from 6a-6p every day, and usually a couple hours on Saturday morning is used to catch up on charting/forms that patients hand me. It too has been wearing on me. I need to take my hour lunch to go home and walk my dog, and do bank/post office/grocery store errands. 20 minute visits are fine for most acute visits and depending on the age of the child, I can get my well childs done in about 25. Unfortunately though, most of my followups I'm trying to address anywhere from 6-15 chronic issues, and whatever acute problems they have, and 20 mins isn't enough time for me to see a patient and chart on all that. Ideally I wish I could schedule my own patients according to how much time

 

I don't think my answer was very helpful but I'd like to tag along with your request on what kind of scheduling works best at limiting off hours charting.

[ventana]

In general 

 

for follow ups = no more then every 15min, ideally ever 20 min

no double booking

Urgent - 10 or 20 min (front desk has to do some triage ie 20 yr old cold for 3 days is 10 min, 90 yr old CHF DM with cold x 3 days is 20 min)

New patients -- 1 hour

Annual PE - 45 min

30 min of doc time at end of morning and afternoon

 

Lunch always annoyed me - places that expect you to work through your lunch are not very nice.  I would say a 30 min lunch (that you take every day as you need the break)     If they are giving you a 60 min lunch make sure you are taking a 60 min lunch (in other words don't work for free!)

 

 

This should give you 8.5 hours in the office, 30 min lunch, 60 min of charting, 7 hours of clinic

 

This is for a 'mature' provider only as it is too much for a new grad

 

 

7 hours for 4 days is 28 clinic hours a week

 

 

 

that is plenty

 

 

MA/Nurse MUST keep ahead of you

 

 

 

factor this to your schedule and it should not be bad

 

as long as you are able to do some of your charting in the room (yup means you are one of the 'those' providers that types and looks at a computer during the visit) and have Dragon medical to do voice to print.....

[EMEDPA]

don't work at home for free...either have the job pay you for your time charting or have them pay for a scribe. can you dictate notes into the emr via dragon or a transcription service?

figure out how much you are actually making by adding all those extra hours into your work hours and you will see you are not making as much as you think.

2 extra hrs/day= 10 hrs/week= 40 hrs/mo= 1/5th of your work you are doing for free. you are working 5 weeks/mo and being paid for 4. not acceptable.

[mainah]

don't work at home for free...either have the job pay you for your time charting or have them pay for a scribe. can you dictate notes into the emr via dragon or a transcription service?

figure out how much you are actually making by adding all those extra hours into your work hours and you will see you are not making as much as you think.

2 extra hrs/day= 10 hrs/week= 40 hrs/mo= 1/5th of your work you are doing for free. you are working 5 weeks/mo and being paid for 4. not acceptable.

 

They got me Dragon, but didn't consider the fact that our laptops are so old they couldn't run the program efficiently. They've been talking about getting me a new laptop for over a year.

 

I write my hours on all my time cards and everyone sees how much I'm working. I put in 57.5 hours last week. I go home and it's either "Am I going to chart, or am I going to eat/do laundry/dishes, etc. I almost never get to study which is frustrating. There's no way I'm going to get more money because they're (supposedly) giving me 12.5k for loan repayment this year.

 

This should give you 8.5 hours in the office, 30 min lunch, 60 min of charting, 7 hours of clinic

 

This is for a 'mature' provider only as it is too much for a new grad

 

 

7 hours for 4 days is 28 clinic hours a week

 

 

 

that is plenty

 

 

MA/Nurse MUST keep ahead of you

 

 

 

factor this to your schedule and it should not be bad

 

as long as you are able to do some of your charting in the room (yup means you are one of the 'those' providers that types and looks at a computer during the visit) and have Dragon medical to do voice to print.....

 

This makes me feel a little better. I've had to do this schedule since Day 1. I even had a rough patch a couple months where I was covering for a physician on maternity leave and another physician who walked out one day and never came back, on top of all my own patients.

 

I have an awesome MA who has figured out my timing almost perfectly, and the rest of our support staff are also wonderful. If it weren't for them, there's no way I'd be able to manage.

[TWR]

Unless you own the practice you should not be taking anything home at the end of your work day except your son.  It all too easy to slide into the take home chart trap and not even get an "atta boy/girl".  Remember, "please help me not to be so busy, I forget to make a life".

It is great that you have an MA that know your routine. Definitely a plus!

[mpbrooks77]

Luckily, I am paid hourly and will get paid overtime if I work it, including charting at home.  I have a 7 year old as well as a 7 month old and want them not to remember mommy has always working.  "Work to live, not live to work".  So spending as little time charting at home would be ideal.  My MA is great and we work well together.  The only problem I have is how the front desk books the patients.  Usually routine checkups, well child visits, and new patients are scheduled for 30 mins.  Everything else is scheduled for 15 mins.  Triage from the front desk is sometimes hit or miss.  ER followup for chest pain - 15 mins, or 78 yo pt for "not feeling well" as a 15 min appointment.  Or sometimes the front desk will stick a 15 min appointment in between check ups which cuts my 30 min scheduled checkup to a 15 min appointment.  Very frustrating.  

 

Thanks for the suggestions!  I probably don't chart enough in the room, so I will do better with that.  The schedule from ventana sounds awesome.  The only thing is that I'm afraid the multiple different time slots would confuse the front desk.  I would love to hear more suggestions on schedules or any that someone uses that's worked well for them.

[jmj11]

I'm sorry to butt in as I'm not in family practice or IM and you asked for only those people to respond. But I do this more as a question than an answer. Would (what I'm about to say) work in your settings or not?

 

I'm in a sub-specialty so I'm narrow and deep.  I am the owner so financial issues are very important to for me to make this work.  Fifteen years ago charting was directed at avoiding lawsuits.  Now, more charting is required to document need for payment by the insurance companies.  I decided that if the insurance companies force me to spend more time in charting, then, they are going to have to pay for that.  So, I do ALL my charting while I'm with my patient and never have charting after the visit.

 

To make this work (without constantly looking at my keyboard) I had to work for two years, first on my own, and then with a programmer, creating templates, drop downs, tags and etc. where most of my charting is by mouse clicks.  I actually have to write (free text) about two sentences for each follow up and about one paragraph for each new patient. Yet, I generate a very detailed 3 page document for each follow up and about 5 pages for each new patient.  I know every question that I'm going to ask and I know virtually all possible answers. So I use drop down paragraphs or sentences for almost every possible combination of answers so I can fill it in with one mouse click.

 

Can something like this work in your environment?

 

I agree with others that you evenings should be with your baby and your mental rest.

[Guest Paula]

I worked for an FQHC and eventually we got a scheduling package that came with our EHR.  The management developed a schedule for patient visits and I had 30 min. for well-child, hospital f/u visits, 45 min for annual exam, 60 min new patient and 15 min for "quick care".  The problem came when a "quick care" visit was really a chest pain or an elderly diabetic who just didn't feel right, or the one with the kidney transplant who came in for a simple UTI (yeah, right!)  All of those quick care visits would screw up everything. 

 

Repeatedly I would discuss with the management and triage nurse that there is no place for quick care in the FQHC and there is no such thing as quick care.  Things did improve when I insisted the RN triage nurse discuss with my LPN nurse how long the visits should be for a quick care visit for the patient who presented as a walk-in.  It did get better.  I was really good at gathering the info in the room on the templates I had.  Before I entered the room I would pick my template, click some boxed that were appropriate such as if the CC: was runny nose, headache, cough I could click those boxes under the HPI, then add the details in the room with the patient. 

This sped me up quite a bit. Plus I had my templates automatically populate the drug list, allergies, PMH so I could quickly review them.  I had those items populated into every chart.  (The other providers in the clinic did not set up their templates that way, but I found it counterproductive to not know what surgeries the pts. had, or their drug list, ).  

 

If your EHR gives you the ability to design your own templates and set the parameters, do it!  I had templates for well child, sports physicals, adult annual exams keyed for male or female, sick visit templates, wound care templates, etc.  It was slick to have my own.  I did do some charting on my lunch hour ( I had 60 minutes from 12-1, but at times the last pt. left after 12).   I would take a 30 minute break and play Candy Crush (haha) then finish my morning charting before 1:00pm.  Afternoons we were done seeing pts. by 3:30, and clinic closed at 4.  I almost always got my charting done before leaving work, even if I would stay for an extra 15 minutes on some days.  We opened at 7:30 and since I'm a morning person, If I had charts not done I from the day before I would finish them the next morning, rather that stand around and chat or eat breakfast like others would.  I'm all about efficiency and this worked for me.  

 

The manager offered to set me up with home EHR access and I said absolutely not, I don't work at home unless I get a raise or compensation for extra hours worked.   They refused to offer any more salary.  I will say I had days that were crazy busy and then days where I was actually bored...many no-shows or cancelations.  It all balanced out in the end. 

 

I just left he practice and start my new job with a larger group so I am hoping that the new EHR will have some of the same capabilities. 

 

Regarding overtime:  Do they pay you time and a half for overtime?  If not, they should.  Plus, it was my understanding that FQHCs are not to base their salary on the loan payback. 

 

Hope this helps mainah and mpbrooks77. 

[SocialMedicine]

i would add to emeds comment .....

 

They cannot expect you to work for free but they can expect you to see a reasonable number of patients and finish on time. if I gave an under 2 year PA 15 patients a day to see and s/he spent 2 hours at home charting after an 8 hour day I would not pay anything extra. Exceptions apply. For example, if the clinic has 0 support staff, or the provider is working in lets say a heart failure or ESRD clinic. 

[mainah]

 

To make this work (without constantly looking at my keyboard) I had to work for two years, first on my own, and then with a programmer, creating templates, drop downs, tags and etc. where most of my charting is by mouse clicks.  I actually have to write (free text) about two sentences for each follow up and about one paragraph for each new patient. Yet, I generate a very detailed 3 page document for each follow up and about 5 pages for each new patient.  I know every question that I'm going to ask and I know virtually all possible answers. So I use drop down paragraphs or sentences for almost every possible combination of answers so I can fill it in with one mouse click.

 

Can something like this work in your environment?

 

 

 

 

Templates work wonderfully for acutes and routine physicals. I have them set up for UTIs, acute sinusitis, bronchitis, low back strain, sports physicals, etc. The problem is that I don't see as much acute as I do chronic care, and then templates are too cumbersome (too much clicking and data entry for multiple complaints).

 

This is a typical patient: Yesterday I had a 60 yo male without insurance or transportation come in for a 3 mo, 20 min followup for T2DM, Crohns, RA, B/L shoulder pain, and lumbar DDD, eczema, and smoking cessation; and my MA finds me and says "he has a list for you," which included hematuria, ingrown toenail, warts he wanted frozen off, what ended up being Dupuytren's contacture, and severe depression. If I were to use templates for all those, I'd spend a lot of time clicking around, and our EMR is sllloooowwwwwwwwww. After each click, there's a 2 sec pause. I know there's no way you can realistically address all those issues and chart on them in 20 mins, but we have such a hard time getting our patients into the office I tried to get in as much as possible. And then had to go home that night to chart on him and all my following patients because I was too far behind to chart after each one.

 

I also make house calls for my patients who are homebound, and I can't chart in their homes. Usually I'm scribbling notes on an old paper encounter form, so this also adds into the equation.

 

Regarding overtime:  Do they pay you time and a half for overtime?  If not, they should.  Plus, it was my understanding that FQHCs are not to base their salary on the loan payback. 

 

Hope this helps mainah and mpbrooks77. 

 

I hi-jacked mpbrooks77's thread so I think there's some confusion between our two situations :) I don't get paid overtime. But I don't get loan repayment through NHSC, the state messed up our HPSA score and it was one below what they were accepting for loan repayment. It's considered a loan stipend from the clnic that unfortunately gets taxed like everything else.

 

 

i would add to emeds comment .....

 

They cannot expect you to work for free but they can expect you to see a reasonable number of patients and finish on time. if I gave an under 2 year PA 15 patients a day to see and s/he spent 2 hours at home charting after an 8 hour day I would not pay anything extra. Exceptions apply. For example, if the clinic has 0 support staff, or the provider is working in lets say a heart failure or ESRD clinic. 

 

I agree, which is why I have been hesitant to say anything. HOWEVER my 2 hours includes updating patients paper charts into the EMR, as the several locums providers before I came around didn't bother to. I also go in early every morning to read through all my scheduled patients charts to take notes on what has happened since they were in last, and any outstanding issue or followups that need to be addressed. Is that abnormal?

[Guest Paula]

This may sound mean but the 60 year old diabetic who came in for diabetic follow up should have been told that is all you can address at that visit.  It is unfortunate patients think they can bring in a laundry list and expect us to clean it up for them in 20 minutes and for the clinic to expect that as well.  I got many of these patients and my nurse was good at saying I only had 20 minutes and would address the diabetes only,with f/u next day or next week for the rest of the complaints. 

 

Patients can be taught to remove their own warts with OTC freeze products.  I don't care if they have insurance or not.  They are choosing to not be insured and it is now a law.  I can't help it  that they are uninsured and it is not my problem if they have to pay for more than one visit.

 

We are not miracle workers. 

[ventana]

those laundry list visits - - - you have to stop them

 

when they start on the list - your answer must be  "okay we are here today to follow up on the T2DM - should we follow up on that, or should we look at ONE other problem?"  Let them decide, then hold them to one problem.  In the Primary care world this is a MUST DO thing - otherwise you die of overload

 

This alone might make your life more tolerable and your MA can and should prep them to this as they are entering a CC (correct?)

[mainah]

Thanks Ventana and Paula--I definitely understand what you are saying, and there have been times where I have put my foot down. Bottom line is that I have a very poor, chronically ill panel of patients 2-2.5 hours away from all specialists and we're currently in the middle of a record breaking winter (50+" of snow in 3 weeks alone). Asking people to leave work and come in for multiple visits particularly during this weather won't fly well, I'm afraid. I excelled at my primary care rotations in school, but they were in suburban delaware and NJ and the patients had nowhere near the complexity

 

I'm grateful for the advice. I feel as though I'm stuck all alone out here!

[Guest Paula]

I get it Mainah.  When you are that remote you gotta do what you gotta do.  Perhaps the triage/scheduler needs to ask more in-depth questions when patients call for an appointment so enough time is allotted. 

 

I worked at an FQHC for a total of 7 years (2 different, but related ones) and loved the complexity of medicine.  THe experiences helped me to become a better and competent provider.  I just got burned out with administration who had no knowledge of medicine or how to run a facility.

 

It was time to leave and I did.  You might come to that point someday and if so, you will know when it's time. 

 

Develop a network of friends and colleagues to get you through the tough times.....I guess that's us on the Forum.   Working in isolation can be a challenge.  Your clinic sounds much more isolated than mine was.  Keep plugging along!

[mainah]

Thanks Paula!

[hj8279]

I'm working at FQHC now and dealing with the same issue. I also have a newborn baby so hate bringing more work home and charting for 1-2 hours extra with no OT pay. My patient population is 90% adult/10% peds, have no admin time and get 30mins lunch break.  I usually skip lunch to catch up charting and reviewing labs. I've worked in other FQHC site in CA but never had any issues like this before. They used to schedule me with mix of chronic pts with women's health/ teen clinic so I think the work load was lighter even though I saw more number of patients. Also I got 1hr admin time every MWF but no admin time with current job.  Anyhow, I'm considering to change to a different setting.

How's UC or ED? 12hr shifts with few days off sounds good as I can spend some time with my baby on off days..

[Guest Paula]

I had an UC job that was staffed with three ACPs. We each worked 10 days a month,  12 hours shift.  It was great and I also worked another PT job in FP.  One of the other clinicians had a  baby so she had lots of time off with the baby and I think she liked it. 

 

The UC job was considered full time so I got all the bennies, CME, etc.  My salary was $73,000   (about $50.69/hr.) You could look for that type of arrangement. I always got my charting done in the 12 hours and never stayed late. 

[hj8279]

I had an UC job that was staffed with three ACPs. We each worked 10 days a month,  12 hours shift.  It was great and I also worked another PT job in FP.  One of the other clinicians had a  baby so she had lots of time off with the baby and I think she liked it. 

 

The UC job was considered full time so I got all the bennies, CME, etc.  My salary was $73,000   (about $50.69/hr.) You could look for that type of arrangement. I always got my charting done in the 12 hours and never stayed late.

Sounds great!

Thanks =)