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psychiatric documentation

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I am looking for help merging quality psychiatric documentation with no time allotted for documentation. Essentially, I am falling so far behind because the bean counters want us to bill on time, and use the maximum amount of time allotted scheduled back to back, collaborate with other providers on the run, and leadership frowns upon our documentation resembling a hospitalist note but prefers it to look academically sound. (I could go on...)

I would appreciate any advice.

 

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I have created macros for much of the documentation I use. Templates with choices that can be selected based on things we see commonly. What EMR are you using?

    I don't agree the above posting. There is no way a scribe would be able to be utilized in Psychiatry. It is difficult enough building a trusting relationship with a patient. Having someone else in the room, even a scribe would add another obstacle to the relationship. Sure in the ED it works fine.... Probably in most other specialties a scribe would be fine. IMHO not Psych.

  I think as long as your format allows for flexibility yet maintains a overall 're usable' structure it will not look like a hospitalist note.

  Do you find yourself typing the same phrase, title, sig, etc.... These are all areas that macros will save you time...

I would be happy to help you create some...

 

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I don't even like scribes in the ER.

macros are a good idea as long as you make sure all the info is pertinent to the pt in front of you and you did the exams you said you did.

too often I see c/c ankle pain with a normal testicular exam noted as part of the nl male macro...

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On 8/7/2017 at 10:23 PM, PACShrink said:

 

I have created macros for much of the documentation I use. Templates with choices that can be selected based on things we see commonly. What EMR are you using?

 

Currently using EPIC for outpatient. I have a few basic macros, but have wanted to develop more, but have not found the time to do so. I have a very basic template for initials and one for followups. 

 

On 8/7/2017 at 10:23 PM, PACShrink said:

I would be happy to help you create some...

I would really appreciate the help with generating some additional macros. Thank you so much for the offer!

 

On 8/7/2017 at 10:49 PM, EMEDPA said:

too often I see c/c ankle pain with a normal testicular exam noted as part of the nl male macro...

This one I can honestly say I am not guilty of, though there have been times I admit that my dragon was slightly inappropriate. 

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On ‎8‎/‎7‎/‎2017 at 10:49 PM, EMEDPA said:

I don't even like scribes in the ER.

macros are a good idea as long as you make sure all the info is pertinent to the pt in front of you and you did the exams you said you did.

too often I see c/c ankle pain with a normal testicular exam noted as part of the nl male macro...

When I worked inpatient there was a pulmonologist who put normal testicular exam on all his male consult notes....WTF?!?!

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