Advice on improving patient/charting time

[EMNP]

Good morning-

I started working at an IM outpatient place a few months ago 2-3 times a week.  All my previous hx is inpatient.

Things in general are going great, the only issue is my charting.  I find myself charting at home sometimes because I have a hard time structuring patient time when going into the room.  Acute visits are pretty good, the issue is with follow ups as patients talk about many other things and drift off a lot from the pertinent things we are following up.. It is difficult to chart some in the room due to the same issue.  I don't want to come off as rude, so I need some help.  As my number of patients keeps increasing, I keep finding this more difficult at times.  I am seeing around 20-22 patients a day, but at times it can be around 25.

1- What is the average time you spend with a follow up patient? DM/HTN/Hyperlipidemia, etc..

2-  What is your routine when you go into the room. 

3- What is the average time you spend in the room for an acute vs a follow up visit?

4- What techniques do you have/use to keep patients on topic and have the pertinent conversation/exam and then get out of the room?

Any other advice/input is greatly appreciated. 

[thinkertdm]

1. I get 30 minutes with each patient. 
2. I get them from the wr.  “Hi mr smith, I’m thinkertdm, pa.  What’s going on with you today? (As the rn already asked, I know.  I just want the patient to tell me)

usually at this time, they say I’m just here for my yearly, which is not what they told the rn.  So, as I’m typing into my general use template, I casually say “so…is there anything you want to talk about today specifically?”  Usually this is where they can voice what’s on their mind.  If it’s a lot, or minutiae, I say, ok man you got a lot going on.  I have some questions, then we can see if they answer yours (or something similar).

then I go through my list, date of colonoscopy, if they are a smoker, if they want to quit, family history etc.

then I have their labs printed out, so I go over each one, and write on the page notes for them, like what the tsh is, etc.  

then listen to their heart, etc.

that’s for a yearly physical type of deal.  For a follow up- (and no one actually knows what they are following up for, they think it’s a chance to tell me more issues) I just go down their problem list in a conversational tone.

luckily I get 30 minutes per patient.

as far as keeping them on track- you need to learn to interrupt them and keep it a q&a.  Unless you are drinking a cup of coffee with them, they aren’t your friend. You are their guide.  Guide them.

[Reality Check 2]

Hi there

These are my offerings at just shy of 30 yrs doing this as a PA and going from paper charts and film xrays to multiple EMRs and the world of the patient as a "customer":

A. NO rational IM practice should expect any provider to see 25 patients in 8 hrs - It IS Internal Medicine and by definition - complex. That is a money mill and not a practice. 

B. IM appts should be 30 min - minimum all day, all the time. Annual Exams should be one hour.

C. If you are getting 10-15 min appts - NO, just NO. It is ludicrous and impossible to actually engage with the patient and get anything done, much less pee, eat, breath and make good decisions. 

D. My own personal GP has a 1/4 piece of paper you get on check in - it asks what THREE things are most important for today's visit and a little blurb about how these will be addressed unless abnormal labs or symptoms warrant otherwise and "we may not be able to address every concern today"

E. I get the background from my LPN before seeing the patient. If an annual - I say "Hello Mr Jones, good to see you. For an annual visit, we will touch on each of your chronic medical concerns and Nurse Sue tells me your right ankle is swelling up - we will address that as well" - It sets the tone and what we plan to do.

F. For a problem oriented visit - same Nurse Sue gives me the rundown and already tells the patient - "wow, when you called, you said only XYZ was the problem. It seems you have gathered a list. Which THREE of these items is most important to you today - we had you scheduled for specifically XYZ". Again, set the tone and the knowledge that this is an ongoing relationship, not a one stop shopping expedition. 

G. Always prioritize - trash everything else when they have gained 15 lbs in 5 days and have an O2 sat of 88% or express chest pain or stroke symptoms or other alarming issues. I call it at that point - "you have some very serious symptoms that will require all our attention today"

H. I "preload" my charts - our EMR - another long ugly story - allows us into that day's encounters early and I look at old H&Ps or cut and paste MRI or xray results that are to be discussed. I check the social hx and mark it reviewed - if I know the patient super well. Pre Planning is ESSENTIAL and should be started DAYS ahead by nursing staff by gathering the needed data, records, labs, etc and figuring out WHY the patient is on the schedule.

Some nurses can call them day ahead and clarify meds etc and save office time for the meat and potatoes.

    *** If the patient is on the schedule for colonoscopy results and the GI clinic never told them - SCRUB that patient OFF your schedule and demand that the GI office talk to the patient. It is not your job to interpret it.

   *** If the patient has chronic foot pain and you talked about it at last visit and their appt is really for a Podiatry Referral - SCRUB them OFF your schedule and just put in the referral. 

I. Like it or not - YOU HAVE TO TYPE with the patient in the room or you will never ever finish. Even if it is sketchy abbreviations - you can go back and correct. It is an art to look the patient in the eye, converse and then tell them you need to record their offerings - I often say what I am typing as a confirmation of what they just said - I am saying out loud as I type "he says his ankle started swelling without trauma about 5 days ago. It doesn't resolve overnight...."

J. DO NOT WORK FOR FREE. You devalue your hourly wage by working for free at home - yes, this is the pot calling the kettle - I have done it and still do - but not as often and not without compensation or comp time. 

K. Do right by each patient - speed and quantity have no value in Internal Medicine.

Just my crusty old 2 cents 

 

 

 

[ventana]

7 hours ago, Reality Check 2 said:

Hi there

These are my offerings at just shy of 30 yrs doing this as a PA and going from paper charts and film xrays to multiple EMRs and the world of the patient as a "customer":

A. NO rational IM practice should expect any provider to see 25 patients in 8 hrs - It IS Internal Medicine and by definition - complex. That is a money mill and not a practice. 

B. IM appts should be 30 min - minimum all day, all the time. Annual Exams should be one hour.

C. If you are getting 10-15 min appts - NO, just NO. It is ludicrous and impossible to actually engage with the patient and get anything done, much less pee, eat, breath and make good decisions. 

D. My own personal GP has a 1/4 piece of paper you get on check in - it asks what THREE things are most important for today's visit and a little blurb about how these will be addressed unless abnormal labs or symptoms warrant otherwise and "we may not be able to address every concern today"

E. I get the background from my LPN before seeing the patient. If an annual - I say "Hello Mr Jones, good to see you. For an annual visit, we will touch on each of your chronic medical concerns and Nurse Sue tells me your right ankle is swelling up - we will address that as well" - It sets the tone and what we plan to do.

F. For a problem oriented visit - same Nurse Sue gives me the rundown and already tells the patient - "wow, when you called, you said only XYZ was the problem. It seems you have gathered a list. Which THREE of these items is most important to you today - we had you scheduled for specifically XYZ". Again, set the tone and the knowledge that this is an ongoing relationship, not a one stop shopping expedition. 

G. Always prioritize - trash everything else when they have gained 15 lbs in 5 days and have an O2 sat of 88% or express chest pain or stroke symptoms or other alarming issues. I call it at that point - "you have some very serious symptoms that will require all our attention today"

H. I "preload" my charts - our EMR - another long ugly story - allows us into that day's encounters early and I look at old H&Ps or cut and paste MRI or xray results that are to be discussed. I check the social hx and mark it reviewed - if I know the patient super well. Pre Planning is ESSENTIAL and should be started DAYS ahead by nursing staff by gathering the needed data, records, labs, etc and figuring out WHY the patient is on the schedule.

Some nurses can call them day ahead and clarify meds etc and save office time for the meat and potatoes.

    *** If the patient is on the schedule for colonoscopy results and the GI clinic never told them - SCRUB that patient OFF your schedule and demand that the GI office talk to the patient. It is not your job to interpret it.

   *** If the patient has chronic foot pain and you talked about it at last visit and their appt is really for a Podiatry Referral - SCRUB them OFF your schedule and just put in the referral. 

I. Like it or not - YOU HAVE TO TYPE with the patient in the room or you will never ever finish. Even if it is sketchy abbreviations - you can go back and correct. It is an art to look the patient in the eye, converse and then tell them you need to record their offerings - I often say what I am typing as a confirmation of what they just said - I am saying out loud as I type "he says his ankle started swelling without trauma about 5 days ago. It doesn't resolve overnight...."

J. DO NOT WORK FOR FREE. You devalue your hourly wage by working for free at home - yes, this is the pot calling the kettle - I have done it and still do - but not as often and not without compensation or comp time. 

K. Do right by each patient - speed and quantity have no value in Internal Medicine.

Just my crusty old 2 cents 

 

 

 

Best summary I have read in a long time!!

 

my thoughts 

1) type during visit 

2) nursing staff has to support you and get everything loaded 

3) “I am sorry but we need to stay on track” state thus as you interrupt them. 
 

4) see if your EMR has text MACRO”s.  Mine does and I use it for reverent common complaints.  Dumps in what text you assigned I.e. me .PE text is my generic exam that I can change quickly 

 

 

final thing. Most EMR now pull last text associated with an assessment in the A/P section.  Type out generic susinct once.  Ie HTN-good control- lisinopril 5mg qd.  That way each time in the future that gets dumped to A/P and you don’t have to change anything.  
 

IM.  Yup you chart at home sometimes.   Just don’t do to much.  I probably do 1-2 hours per week.  

[thinkertdm]

To me, working from home is as close to a sin as you can get.  Work late if you have to- I do, but when I leave the clinic, I leave the clinic.  You work to live, not live to work.  
 

The va uses (or tries to use, depending on your team) a huddle concept, as reality said above.  I’m lucky enough to have worked with two excellent teams in the past (not currently, unfortunately).  It will trim up some time if you talk about your upcoming schedule with the rn/lpn.

The key piece of advice common is you need to take control of the conversation when the patient comes in.  You direct the flow.  It may not be your personality, but you’ll have to change that, at least while you are in the room.  

[sas5814]

I have worked out a pretty good time cycle. For my routine 30 minute appointments I limit the visit to 2 complaints. I don't chart in the room , I take notes. Then when my nurse is rooming the next patient I do my computer work in my office. I get a little behind sometimes but not very often.

You can't let the patients overwhelm you. It is simply impossible to see a 75 year old with multiple complaints and a list of a dozen things they want to talk about (and talk and talk. I love my old people but they want to visit too much.)

We use the Team concept but we have been so short staffed since I have been here it rarely sticks for long. Today my LVN is on vacation and they took my RN for other duties they need an RN for and are giving me an LVN that I have never worked with. My team, when they are all here, is awesome and we have a work flow that really keeps things on track.

I never never never never chart or do other work at home. Never.

[rawwrr342]

1- What is the average time you spend with a follow up patient? DM/HTN/Hyperlipidemia, etc..

Time can vary from 15-45min, depending on type of visit and type of patient. I see about 18 patients per day on average and I think that's a lot. 

2-  What is your routine when you go into the room. 

I always try to type my HPI and put orders while I'm talking to the patient. I always wonder if patients think this is rude but they actually don't seem to mind. I definitely fall behind if I don't do this. 

3- What is the average time you spend in the room for an acute vs a follow up visit?

Acute visits sometimes take longer than follow up visits, especially if it's a new patient or they have a complex problem. Follow up visits tend to go more smoothly once their medical problems are stable.

4- What techniques do you have/use to keep patients on topic and have the pertinent conversation/exam and then get out of the room?

Controlling the conversation is actually quite hard for me sometimes especially with the chatty ones. If they go off topic I usually reel them back by just asking another question pertinent to their medical problem.