Finishing charts each evening at home

[EMEDPA]

We are primary care and are about 15 months into Eclinical works as well. I'll admit the first. 6-8 months were painful. I'm much faster now. 20/day with complete charting is a full day now. you will need to learn short cuts and master the order-sets and pre- entered templates. Gather your favorite rx's etc..... I also do spend maybe 1 hr in the evening if I'm laying around, scanning next day schedules, the hospital records (ps great source to data-mine for dx's/icd codes) .. Chin-up you'll get faster

 

 

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"short cuts" aka "work arounds for an inefficient system". in epic I use the templates but often end up just free texting huge sections becuase no template covers the presentation adequately.

[delco714]

Right now we're dictating EVERYTHING. and by necessity, almost every note has to have all parts until we implement macros and better templates. It's HELL

[shani26]

Also new to FM and also a new grad (5 mos out), we use eCw and we just moved to version 10. I have to say we just started it this week and I find it easier to use than version 9. Besides doing templates, you can also do specific word phrases that are programmable that may be helpful. For example we use a lot of interpreters and so we have to just hit two keys and it shows up in the chart.

Ive been only out 5 mos and Im already up to seeing 16 pts a day( when they show up), so they gave us a session- a half day either morning or afternoon where patients are not scheduled. So that is pretty helpful. Maybe something to discuss?

Also, I wonder if previsit planning with your RN could possibly help some, especially with new patient visits.

[cupojava]

To the OP:

Seasoned PAs above have given you a very basic but important advice--that is, do not work or free.  Stop finishing charts at home.  You have to draw that line that your time off is yours.  

I second the suggestion regarding preparing your charts the day prior.  If you know that your diabetic patient is coming in the next day, the nurse/MA should be checking if the patient has had A1c done? m/c ratio?  Same thing with other chronic disease management.  

Read the EHR manual.  I learned more from that than what I was shown.

Medical IT is evolving and it is here to stay.  We can't get rid of it.  We have to adapt to it.

Good luck to you.

[GetMeOuttaThisMess]

Manual? When my last employer bought their system (Prime Suite) there was no manual. Most of our learning was self-taught.

[cupojava]

You know, I've heard that said before. And I've proven people wrong. My training did not give me a physical manual but if you have a "help" button in your EMR, click it. I printed it and still use it.

Done this at the previous job too with a different EHR. And I'm sure with a little google search, a manual for Greenway will produce some results.

[fyrelight74]

I'm a newer grad myself, in a family med office with one doctor. Our patient schedule is M-Th 8:30 to noon, and 1:30 to 5.  Friday 8:30 to noon. Dr and I have 28 slots each we can fill with patients on full days, but in actuality (we're trying to build up the practice), we haven't seen over 38 patients together daily yet.  Sometimes I work solo; I think the max I have seen is around 22-24.  I generally jot notes on each patient as I'm talking (even though we have computers in the rooms, I don't like not facing my patient), and when I get time, I chart into the EMR in my office.  We have GE Centricity, a very good EMR.  I'm paid a low base hourly plus an amount per patient (my idea, since we started off slow and need to build up the patient load).  I generally will stop at 8 hours for each day, and whichever notes I don't do, I will get them done the next day, and so on.  By Friday, sometimes, I have many of Thursday's notes waiting for me still, but since we don't see patients Friday afternoon, I get them done then.  It works out well.  In between charting, I'm answering phone notes, doing refills, interpreting lab results, etc.  I was previously an MA/Scribe, so I do type very fast (at my prime, was getting 75-85 wpm).

[UGoLong]

I'm not in primary care -- cardiology -- and we have GE Centricity with some forms I designed/assembled when we started EMR 3 years ago.

 

Patient encounters are not quite as freewheeling as with paper charts, but we seem to keep up. The forms lead through vitals, social history update, etc (loaded by an MA), then complaints (our common ones plus free text -- also started by MA and edited by us). Then there is a review of systems page, physical exam (with a button to put in the default values), and page for new test results, and another for the plan, which we free-type. Meds are updated on a med tab and prescriptions go out automatically when we sign.

 

I sit facing the patient with a laptop on my lap and I look up a lot. I start out without doing much from the computer, with a few general questions. Then I go back and quickly review their last visit (complaints, findings, plans). Then I go through all tests, hospital reports, phone calls, etc we have about the patient -- in chronological order -- since their last visit (sometimes none and sometimes multiple admissions). Then I walk through our forms.

 

I have to work sometimes to keep the patient talking about what we're talking about -- I want lots of details about chest pain before they wander off to tell me about their arthritis. And they'll sometimes ask me about their EKG very early in the visit and I gently tell them that we'll get to that (the result goes on our testing page) but first I want to make sure I know what's happened with them since we last met. That seems to work.

 

I can type pretty well, thanks to my late Mom forcing me to take typing in summer school when I was in high school. Those days of walking to school when my friends were still in bed paid off, I guess! I still cheat and look at my hands when I type, so I am not a pro but I am fast. (We have people who will look at the letter that is autogenerated from our transaction report and they will fix spelling, etc). I insist on finishing my charting before I leave the room if at all possible. After 3 years, I can.

 

The overall process is faster than the paper charts were, if only because test results and the other supporting documentation are right there. The chronological approach (start with the last visit and move forward) adds some structure to the patient encounter. Sometimes though, I have to change my approach. The patient who is in tears when you walk into the room, etc. 

 

I can appreciate how a non-specialty setting might make this harder. In the ER, you see a wide range of patients and conditions, as well as perhaps having way less relevant patient history. A primary care setting would usually have lots of history, but still more variety as to complaints. Managing forms in that environment probably would be more difficult.

 

I haven't worked anywhere else as a PA, so I don't know what the rest of you face. Perhaps it is because our transaction forms are pretty straightforward and flow like we want. I think that, if your forms don't match the way you think and manage a patient visit, then it might be forcing you to do too much thrashing around and take too much time. I would hate to do charts after hours, not only because of the time it would take, but also because the patient is no longer in front of you and you might not remember everything.

 

After 3 years, there are elements of our forms I would like to change, but I don't have the time. I'm not sure I remember how to use the Forms Editor anymore either. I guess there is not much impetus in our practice to do that because what we have seems to be close enough for now.

[fyrelight74]

I'm not in primary care -- cardiology -- and we have GE Centricity with some forms I designed/assembled when we started EMR 3 years ago...

 

After 3 years, there are elements of our forms I would like to change, but I don't have the time. I'm not sure I remember how to use the Forms Editor anymore either. I guess there is not much impetus in our practice to do that because what we have seems to be close enough for now.

I don't think our office even bought the "Forms Editor" for GE Centricity.  We deal with the template we were given.  Works pretty good for our primary care office.  One day, if I have time, I would like to edit a few things in the templates, but we have been talking about that for years.  

[GetMeOuttaThisMess]

^^, fyrelight74, I don't mean to be a DebbieDowner but what would happen if something were to happen to yourself during the one to two day window between a patient visit and the time that you document the visit?  As I'm typing this, what would happen if something happened to the patient during this time interval without office documentation to back you up?  This isn't directed at you specifically, it is just a thought that fell right into my brain as I was thinking about the delay in documentation.

 

As an aside, since it is the two of you starting out together, have you, or did you consider asking for a life insurance policy on the physician in the event of their demise since your employment is dependent on them ($100K term policy for example which would most likely be dirt cheap assuming the SP is young and otherwise healthy)?  I did the same thing as yourself years ago when I left the ED with one of my SP's who was boarded in FP.  Practice started slowly and wasn't viable for the two of us together so I left after a year.  This individual later died of causes which are not known to me (younger individual) but theoretically could have just as easily happened while I was there.

[Guest Paula]

Can you actually get a life insurance policy on a physician that you work with?  I work with a sole physician and my greatest concern is his demise (he is healthy to my knowledge), but if he does, I am toast.  

 

How does one get a policy?  Is it through the employer?  Do you talk to the physician first?  Would it compromise your job if an employer knows you have the life insurance policy.....after all they could just hire an NP instead and not fuss with PA issues like this?

[GetMeOuttaThisMess]

He/she takes out a term-life policy and lists you as the beneficiary.  I just used the $100K as a round figure roughly equivalent to one year's salary so that one could continue with life's expenses while seeking out a new position.  Depending on age and any associated risks, you're looking at less than $300-$500 annually in most cases.  I'm at $984/annually for a fixed (no rate increase) 15 yr. term at $600K.  Think of term as "rent-a-policy" which has no underlying cash value aside from the payout itself.  BTW, life insurance payouts are non-taxable income as I recall so you get the full $100,000.

[fyrelight74]

If I need to wait a day or two before I can finish my notes, it's ok.  I get enough information jotted down, so there is no problem.  

 

Occasionally, we will get a call from the pharmacy the same day stating the medication wasn't covered, so I will change to another brand, etc.... and in my note, I make a statement such as "The patient was initially prescribed X; however, the pharmacy called the same day and indicated it was not covered.  A new prescription for Z was sent over to the pharmacy."  Or, if a patient has a reaction or worsening symptoms and calls back before I wrote my note, I indicate that in my note as well.

 

Haven't run into any real problems yet.  My doc has been solo for 7 or 8 years; he just added me has his "number one" (think Star Trek).  He has life insurance, which goes to his wife.  In the event he were to die, I would probably file for unemployment and look for another job.  

[GetMeOuttaThisMess]

Depending on your current income level and financial needs, you may be unpleasantly surprised at how little unemployment covers.  When you say you have the info jotted down are you referring to a separate note/legal pad as an example or something directly tied into the EMR?  If a personal pad or some such I'm not sure the admissibility status of other records that aren't part of the official record.  I'm trying to recall how this was handled with regard to after-hours calls several decades back handled from home.  I know that it was strongly suggested to enter the record into the chart as soon as possible the next possible day.  In this case you would want it to be admissible.  Not trying to be a hardarss, just trying to watch out for you and make sure you've got all your bases covered.  It wouldn't hurt to ask physician about the insurance.  It isn't an unheard of request.  I would think it was a reasonable request of a professional hire such as yourself.  All he can say is "no".

[fyrelight74]

My doc has never been in a lawsuit; he does his notes the same way.  It's basically a profile sheet we use to jot info onto.  After dictating our notes, we give the profile sheets to our manager who scans them in.  I'm not that concerned.  Thanks for your concern.

[familygal]

Thank you to everyone for the advice on charting; I will certainly take this advice and work with it.

The docs did mention something to me about getting a Dragon, so that is still an option.  To tell the truth though, what takes my time is not necessarily the typing-I'm a decently fast typist and I usually type the HPI in the room while the pt is talking to me.  I am starting to get faster with patient encounters and with experience I have been able to make my medical decision-making faster as well.  I'm finding what is slowing me down is typing my phsical exam and inputting the orders into the "plan" section- finding the correct RX and e-prescribing it, loading up diagnostic imaging and lab orders.  I have made some favorites but it is definitely time to update my favorites list now that I know what I like and use often.  My MA also needs some more guidance, part more EMR teaching from the practice, and part delegation from me.  This I am working on as well.  Sometimes I will just do something myself that I know could be delegated because I can get it down faster or it's just easier.  I really need stay in the mind frame that I am the boss of my MA and she's there to help me get through the day.

 

It is good to read what others do to get through their clinic.  I'm always up for more recommendations.  Thanks again.

[Joelseff]

He/she takes out a term-life policy and lists you as the beneficiary. I just used the $100K as a round figure roughly equivalent to one year's salary so that one could continue with life's expenses while seeking out a new position. Depending on age and any associated risks, you're looking at less than $300-$500 annually in most cases. I'm at $984/annually for a fixed (no rate increase) 15 yr. term at $600K. Think of term as "rent-a-policy" which has no underlying cash value aside from the payout itself. BTW, life insurance payouts are non-taxable income as I recall so you get the full $100,000.

This is what my SP did for me.

 

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[problem child]

Anyone else have a system that basically requires them to chart at home in the evenings?  I really don't know how I can continue to sustain this!  I generally take about 2 extra hours in addition to my clinic hours each evening to finish up my progress notes on our EMR system (this doesn't include going through labs and stuff).  I'm about 5 1/2 months into my first family practice job (however I've been out of school for nearly 6 years) and the evening charting every night is killing me.  Granted, I'm still a bit slow and I know I'll be faster each month.  I see 14-16 patients per day at this point, working my way up, and we are using eClinical Works.  Its a challenge for me to finish the note on each patient visit during the patients' visits; I will try to get in most of the HPI while I'm there in the room, the physical exam, and bits and pieces of the A/P and billing.  There's tricks with the system to make it go faster that I'm still getting the hang of.  I've tried to limit the amount I type, i e avoid typing long paragraphs, but the charts just don't seem to get finished and I'm ALWAYS working on them  in the evenings.  I would think it is just me, but my two SPs aren't able to finish their charts during the day as well and do a significant portion of their charting outside of clinic hours.  I have never had this much extra "homework" in other jobs (yes, yes, the nature of FP)  When I talked to a few of my friends who work in primary care, they think it might actually be an inherent fault in the EMR system.  Nonetheless, if anyone has any tips/tricks for quicker charting it would be much appreciated!

 

I never take a mon-fri "8-5" job bc as a PA, there's no such thing. I usually prefer 3/12s, or 5 on/5 off; 7 on/7 off...something like that, bc there is no such thing as an 8 hour day in medicine. especially inpatient. especially surgery.

 

I would just recommend try to split a job with someone else and offer to do alternate weeks, or alternate 2/3 days/week. NEVER take a chart home!! I've actually had a surgeon smile to my face telling me how his electronic system would allow me to do my charting at home, in the evening, on my computer!! really? that's something I should be excited about???

 

working for free (ie, we are salaried and we just work "until we're done") is a flat-out rip-off, and I won't do it anymore. I think it's one of the main ways PAs should take individual responsibility for protecting each of our collegaues - known or unknown - in this profession. when you are interviewing and talking about hours, make sure you ask, "who will I be signing out to (at the end of my shift)?". it's a nice way of finding out if there IS someone to sign out to, or if your just going to be left there until the work is done.

 

locums is a good way, too, to make sure you're being paid for every hour you work, although the tax liability can be worse if you work as a (1099) contractor. if you go locums, try to be paid as a salaried staff. you still  get the hourly rate, but the agency takes out your taxes and covers half your SS and FICA taxes.

 

good luck!