Break the Unpaid Cycle of Charting at HomeMay 09, 2022
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Charting or documenting is a critical part of excellent patient care. However, it often becomes overwork. That is, work that keeps you late or you end up taking home with you. If you’re stuck in the defeating cycle of completing work at night or on the weekends, this episode is for you. And although I mainly discuss charting by physicians, the principles I share in this episode can be applied to any necessities work. Your “charting” can be any task you find yourself routinely behind on.
Throughout addressing my own tendency to fall behind, I was forced to examine the true reasons behind it. Not just the obvious, surface reasons (such as having too many patients) but the root causes. In this episode, I share some of what I discovered and how it resulted in taking chart work home. Perhaps you will be able to relate. I also share what I did to break the unpaid cycle of charting at home and hope my discoveries can help you.
“I think it’s a major cause of dissatisfaction with physicians and other health care providers. I think this is probably true in other fields as well. All of the work that we do that is sort of, in a sense, unpaid, on our own time. It can create a lot of feelings of resentment, dissatisfaction, and sort of sucks some of the joy out of our day and the rest of our life.” – Dr. Sara Dill
What You’ll Learn
- The overwork of charting (or similar necessities work)
- 3 main reasons you fall behind
- Underlying thoughts
- Spread that leads to burnout
- Potential issues from late charting
- 4-Step Solution
- Personalized workflow
- Prioritize it
- Use your resources well
- Be good with A- work
- 3 true purposes of charting
Contact Info and Recommended Resources
Connect with Sara Dill, MD, The Doctor’s Coach
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I’m Dr. Sara Dill, and this is the Stress-Less Physician podcast, episode number 13. Welcome to the Stress-Less Physician podcast. I’m your host, Dr. Sara Dill, MD. Using my unique combination of coaching and mindfulness tools, I will teach you practical ways to reduce your stress level, feel happier at work, and create a better balance between your medical career and personal life. If you are a busy practicing physician who wants to design a life and medical career that feel good to you, you are in the right place.
Hey, everyone, how are you? I am doing great today. It is a beautiful day here. I will say it is the Santa Barbara fair. I live out in Santa Barbara in California. And there’s a local fair, which is mostly amusement rides, sort of carnival rides, and games. And I live pretty close to it, close enough that our neighborhood is where a lot of folks come to park for free. And so it’s sort of funny just to watch everyone cruise through our normally quiet streets, and then try to negotiate for parking, and all of that. So, we are in the middle of that. But hopefully it is quiet enough that I can do this podcast.
So today I wanted to talk about something that many of us physicians really find as a source of stress and what I would consider overwork - working sort of more than we want to, working at times we don’t want to be working. And so what I want to talk about today is charting and documentation. So, if anyone’s listening who is not a physician, what I would do is encourage you to find an area of your life where maybe this applies to you. Do you have something that you tend to procrastinate or that builds up, that spills over into free time, vacation time, nighttime, other kinds of work, or maybe bill paying, or, you know, we just got through tax season, like, all of that. But for all of you physicians, you know what I’m talking about.
So, charting and documentation - I specifically want to talk about how to stay on top of it, how to finish all your charts every day, and how to not do charting and patient care, when you are not working when you’re off, which for many of us is nights and weekends. For those of you who work nights and weekends, I want you to think about how not to do charting or patient care when you’re not at work. So, whenever that might be. And if you are a physician who struggles with this, and I know you are out there, because I coach a lot of you on this. So if you’re someone who has a lot of charts open at the end of the day, if you routinely have to do documentation and charting at home, at night or on the weekends, or even on vacations. If you’re behind right now in your charting, this episode is for you.
I am going to do another episode on electronic medical records or electronic health records. I think that’s worth talking about, too. And I’ve been thinking a lot about this, because I’m in the middle of transitioning in our practice from one EHR to another. But I am going to save some of my thoughts about that for another episode.
So, let’s talk about why do we get behind on charting and documentation? Or why do we not finish it? Most of the time, what clients tell me or what I read on social media, is that they have too many patients or there’s too much administrative burden, there’s too much paperwork, people aren’t respecting their time. There’s just too much to do. And I would say, maybe that’s true. Can you check in and actually evaluate, why is it that you get behind or not finished charting? Do you know anyone else in your organization or in your practice? Who maybe sees roughly the same number of patients or same number of cases and does seem to stay on top of things? Who does seem to get things done? Is it possible that it is possible? So I would just sort of start there.
I find that the reason a lot of us get behind or not finished charting, comes down to several things. One is sort of poor time management. Often, we’re getting interrupted, we’re doing other things, we’re sort of here or there. So how are you managing your time? How are we managing our time? For a lot of physicians, they have a lot of thoughts about documentation that then causes them to not prioritize it, to not sort of focus on it, to procrastinate with it or to delay it, to push it back to another time.
So, some thoughts that I’ve heard are that the documentation is not as important as face-to-face time with the patient, or the documentation or charting is not really part of the visit, right? We have to spend all of our time with the patient, whatever time is allotted to us. Some people think that maybe patients don’t want to see us documenting, again, that it’s more important to be face to face or not be seen taking notes or doing any part of the notes. So, you could notice here, what are your thoughts about documentation? And are they creating the result for you that you want? Are they creating the result of getting it all done quickly, efficiently, and by the end of the day?
I would also say we get behind on not finished charting, again, because of distractions and interruptions. Part of this is very common in medicine, where people are coming to us asking us questions, maybe we have pop up alerts or messages, there’s our to-do box, our inbox. How often though, do you also interrupt yourself or distract yourself? How often do you get on email or Facebook or Instagram, rather than chart? I know I’ve certainly been guilty of that. And sometimes maybe online shopping or other things. How often do you notice when your own focus on patient care documentation, getting done, being efficient, sort of wanes or wavers? How can you take responsibility for that too? Do you encourage interruptions or distractions? Also, some of this is problem solving? Are you in an area where people can just come interrupt you? Can you pause for a moment and finish what you’re doing?
I would also ask yourself, how do you prioritize charting and documentation and finishing it? Again, this goes back to some of our thoughts about it. Do you think that it’s important? Do you think that it’s part of your job? Do you make it a priority to just get it done? Some of the docs I work with think it’s a waste of my time, or it has to be perfect. Or it takes so long to document, it’s not worth starting, if I’m about to see another patient, or about to be interrupted. You could notice what your thoughts are, that are, again, creating the result of not finishing your charting, maybe having a backlog of it, postponing it, doing it at home, doing it on the weekends, you think, “Oh, I’ll just catch up later? Not a big deal.”
That leads into my next question, which is, why is it important to not procrastinate it? Right, why is it a big deal? Having a lot of charts open having to work on weekends and evenings and vacation time and when you’re not at work? I think is a huge deal. One, I think it’s a major cause of dissatisfaction with physicians and other health care providers. I think this is probably true in other fields as well. All of the work that we do that is sort of, in some sense, unpaid or on our own time. It can create a lot of feelings of resentment, dissatisfaction, and sort of suck some of the joy out of our day and the rest of our life, right? It’s sort of the creep or the spread of what we do into other areas of our life.
I think that charting and administrative paperwork and all of the burden of that, and especially if you’re someone who isn’t very efficient in finishing it, and tends to find that they have to take it home at night, or work on it on the weekends, or when you’re otherwise off. I think this contributes a lot to burnout that we’re seeing as well. And why wouldn’t it right, like we need to recharge and rest and have time off. Again, working when you’re home, takes away time from friends and family, maybe just downtime, doing what you want.
Another reason that it’s very important to look at delays and documentation that not only affects your quality of life, but that if you document long after the visit, you often sort of maybe misdocument, you might forget diagnoses or not include them. You might forget procedures or some of the details of the procedures. You might mis-bill, not capture all the work that you did You might forget to put in a medication or an important conversation that you had. I know some physicians who have charts from weeks and weeks and months and months ago. And again, this is something that I remember when I was a resident, we did paper charts. There was always that one attendee who had stacks of charts in her office. So this is not purely something from electronic documentation, or computers or anything like that. This could just be a pattern of behavior, a pattern of not completing things in time.
But again, and this I’ve certainly experienced, even a couple of days out, or maybe a week out, is trying to remember what else happened in the visit, what else did we talk about, right? Which patient was this? I see a relatively high volume of patients in a relatively short amount of time. I’m great with faces and not so great with names. And so trying to recall the visit can be challenging after the fact. And then I would say it’s also important, because documentation and charting is actually part of our job as a physician. I would say it’s just as important as knowing how to take care of patients, as knowing whatever your own expertise or arena of expertise is. I think it’s just as important to be able to keep an accurate and complete record of what you did, why you did it, and what the plan is. And to communicate that to other physicians, other members of the healthcare team, as well as to patients, right? They all have access to their records, and to other interested parties.
If you don’t do a good job of charting, or documentation, patient care could suffer. I know I’ve been frustrated by either seeing a patient back and follow up with whom I’m not familiar, or I haven’t seen them before. And when the note isn’t completed, it often makes it very difficult for me to pick up where someone else left off. It can negatively impact patient care. Or when the documentation is very sparse, that can also be an issue.
So, my goal for everyone listening for every physician out there, is to finish all of your charts every day without staying late, at least 90 to 95% of the time. That’s sort of my goal. More days than not, way more days than not, I’d say I’m probably at 95% of the time. Every once in a while, my last patient chart, or maybe two charts isn’t quite completed from the medical assistant’s standpoint. And so depending on what my evening looks like, I may just consciously decide to go home and do it in the morning, when I get there. I like to come to work a little bit early, so I have time to finish that.
So again, it doesn’t have to be 100% of the time—although that would be my goal. I would aim for 100% charts done before you leave and leaving on time. No work hanging over your head at night or weekends. Just spend a minute thinking about how amazing that might be for you, and what else that might make possible for you in your life. And also notice how much more enjoyable your practice might be. So always start by asking yourself good questions. How can I do this? How is this possible? Make sure you weren’t asking sort of dead-end questions like: why is this not possible for me? Why am I the person that’s never going to be able to finish my charting? You always want to ask a question that’s going to lead you in the direction and help you find evidence for and solutions to create the result you want.
So, I would just start by wondering: how can I be someone who doesn’t work on charting and documentation after the fact? How can I be someone whose free time is really free time? How can I do this? How is this possible for me? I will say the answer is typically not seeing fewer patients. It’s not reducing the input, really. It may be for a few special folks out there. But generally, it’s better time management. It’s better focus. It’s not procrastinating on the charts, and often shifting your viewpoint to seeing it as equally part of patient care. Just as important as knowing your specialty is being able to document in a timely and efficient manner.
And I will say that the reason I don’t think the answer is to see fewer patients is because on days when I see fewer patients, I noticed that I often waste or fritter away more time. I have thoughts about like, “Oh, I have plenty of time. Look, I’ve had to no shows or look how lightly I’m booked, I’ll make sure I get my charts done.” But then I sort of procrastinate. I get on social media, I talk to a colleague, maybe I don’t sit down and focus. So, I would just check in with yourself. Is it possible to do this without cutting back on your patient volume? Or what you actually have to do?
I have broken this down into four steps, and I will walk you through them now. So, the first step, I would say is to start by knowing your workflow. So, some people recommend completing the chart right when you see the patient. And before you move on to the next patient, the chart is done. You finish your documentation, you allow for that as part of your time allotment for patient care, and then it’s done. I think that can be very effective when you are the one doing most of the documentation. So, in terms of knowing your workflow, do your medical assistants also complete your notes? Do they act as scribes? Do you need other people to finish their documentation before you can sign off? How many patients do you see in your day, in your hour? Do you tend to prefer to see patients right on time, or are they often back-to-back?
So, ask yourself if you can do notes during and immediately after the visit? Or whether it makes more sense based on your workflow to do them a little bit later, but still that same day? Also know what works better for you. Are you good at typing? Do you prefer to dictate? Do you prefer to have a scribe? So, for me, my workflow is that we have medical assistants who scribe for us. And so I often need them to finish putting in the biopsies, the pathology requisition forms, finishing up the lab orders and finishing their documentation before I go in and complete my part. So often, maybe with a very straightforward patient, with whom we don’t do much, the note might be ready for me to sign off immediately. But more typically, it’s usually ready within 30 to 60 minutes. And again, it really depends on our staffing.
So, this works well for me. In the past, I’ve dictated notes, I’m a much better dictator than typist. And otherwise, using different electronic records, which I’ve used multiple ones, you can get very good at smart phrases or quick phrases or templating. There are so many different ways you can do it. So, the first step is to know your workflow. And this might help you decide, am I going to be someone who finishes every chart immediately before I see the next patient? Or does it actually make more sense based on other parts of my team needing to do their part before I do my notes?
The second step is to prioritize charting. What are your thoughts about it? Again, I like to think this is something I want to get done now, I don’t want to do this later. I like to think this is equally important. Doing my charting is just as important as every other part of that patient visit. I also try not to go back in multiple times. So, if my medical assistant is done with the chart, and I have five minutes before my next patient, I will go in and finish it. Even sometimes if I just have two minutes, I just prioritize it. And if a medical assistant comes and wants to present the next patient to me, I will just take a minute or two and finish my chart before moving on in that case. It takes a lot more time once I’m in the record, to go in and out, in and out. So that’s something that works for me.
In terms of prioritizing charting, I want you to use self-awareness as well. And just notice, maybe ask yourself, Do I tend to procrastinate? Do I, whenever I’m sitting down, just finish one of my charts, just sort of bang out one of them. Or do I find myself like checking email, personal email, getting on Facebook, maybe Instagram, maybe doing other stuff? Just notice what your own habits are. Can you just redirect and be very focused and prioritize your charting, so that you don’t have to do it later?
The next step is to use the resources you have. Train your staff, whatever staff you have. Make sure they are helping you document and finish your chart. Even if you don’t have a scribe, can you be very clear in your expectations? Can you make sure that whatever medical assistant or staff you work with really knows what you need from them? I like to start with a lot of positive feedback. And then also be very consistent with, please put this in the chart or please document this, whatever that might be. Use everyone else you have to help you as well. That’s part of the teamwork. Taking care of patients is a team activity.
I would also say become an expert and a very efficient user of your own personal electronic medical record. Can you become a super user? If there’s someone in your practice or someone you know who likes that electronic record, who seems to use it well, whose notes you admire? Try to figure out what they’re doing that you’re not doing, maybe shadow them, maybe ask them questions, take them out to lunch. Become someone that really takes advantage of all of the features. Become the boss of your electronic record.
Use any other resources you have. So, I have a scribe. The practice I joined several years ago, uses medical assistants as scribes, and I love it. That actually would be a deal breaker for me, for any future practice. I will never not work with the scribe, quite honestly. So you could just notice that. If you’re in a practice now that you like, but you don’t have scribes, you could just decide to be okay with that, or you could explore other ways too that may shift some of the documentation burden off of you.
And then the fourth step, in terms of getting better, achieving this documentation and closing out all your charts, is something called B-minus work. I’m actually going to call it A-minus work because B-minus doesn’t sound that great to me. But this is basically the habit of prioritizing, done over perfect. This idea can change your life, if you let it. And again, this is applicable in pretty much every arena. So whether you want to call it B-minus work or A-minus work, it’s basically the idea that done is better than perfect. This is the idea that you don’t need to, nor should you even try to write the perfect note. I used to love writing beautiful notes, the perfect story, the HPI, the narrative, making it all flow, and then a beautiful description of the patient’s, you know, skin complaints or skin findings, all the language, all the adjectives. Anyone who knows dermatology knows we’re very descriptive, and very particular about our descriptions as well. And then the assessment and plan, really explaining everything.
I love beautiful notes. And yet, I don’t want to spend 10 minutes, 20 minutes, even five minutes really documenting in a perfect fashion. So, ask yourself, what is the purpose of our documentation or charting. So, the first purpose is clinical care, right? You need to document what happened, what’s happening with the patient, what you did, what the plan is for medical care, so that you and others know what’s going on with the patient. So, you need documentation for continuity of care, and just providing good clinical care. You need documentation and good charting for billing purposes. This is how you support how you bill.
And then you need documentation and your chart notes for medical legal documentation. So, you need to be able to have a record of what you did for medical legal purposes. So clinical care, billing and medical legal. That’s it. If it’s not in the chart, it didn’t happen. So, when I see B-minus work—or again, I like A-minus. A-minus sounds better to me. I do not mean writing notes that are illegible. This actually a big perk of our electronic records now. I don’t know if you remember those illegible notes in years past. I don’t mean writing notes don’t have details, important clinical details of what was said and done or not done, what procedures were performed, what medications were prescribed. So I don’t mean that you’re leaving out important details.
I mean, allow for the note to not be perfect. Maybe there’s some typos. Maybe it’s not quite how you would say it. Sometimes the electronic records, put things in sort of awkwardly or non in perfect English. Some of the staff that I work with maybe phrases things not exactly how I would say things, maybe there’s some weird formatting. So, allowing for that. Do you go back and correct typos? Stop it. You don’t need to unless it disrupts the actual meaning of the note. That’s what I do, right? Otherwise, if I was correcting all the typos, I would spend a significant amount of time more than I do on each note. So, is it accurate? Does it represent what we did? Is everything in there? And maybe it’s not perfect. Is it good enough? Is it done? I like to sort of compete with myself on how quickly I can finish a note. And have it be a note that’s good. It’s good enough.
The last thing I can recommend for improving your charting efficiency, this is something I do and this is something I guess probably many of us do this, is to put my plan for when the patient returns at their next visit, in my assessment and plan. I’m already thinking about not only what am I going to do now, but if the patient responds, or if the patient doesn’t respond to my treatment, or if the diagnosis is this, what am I going to do? Or if the diagnosis is this, what am I going to do? So, I already am telling myself in my head, sort of what my next few steps will be, and I put that in my note. I like to tell my future self, right, when I see this patient back, what was my thought process? What am I going to do next? I don’t like to think about things twice. It makes it much easier for me when I go see a patient, I just check my last note, and I read what I told myself my next steps were going to be, so I don’t have to rethink it. That saves me a lot of time in the future and makes my documentation next time around more efficient.
So, I like this idea of having your own back. Make it easy on your future self for when you see this patient back, or for your colleagues. I like to know their thoughts about their next steps as well. Definitely makes it easier. This was longer than I thought it was going to be. I thought this would be short and sweet, but this can change your life. It really is possible to be a busy clinical physician, or a busy physician in any kind of practice, whether it is hospital based in a large organization or private practice, seeing all the things doing all the things and getting your charting done that day. It can change your life and make you enjoy practice so much more. That’s what I wish for you. If you need help with this, please, please, please reach out. I would love to offer you some free coaching on this. And let’s see if we can get you enjoying all your free time. All right, everyone, I’ll talk to you soon. Bye.
If you are a busy practicing physician ready to start feeling less stressed, enjoy work more and learn how to create a more balanced and sustainable medical practice and life, sign up for a consult call with me at Saradill.com. That’s S-A-R-A-D-I-L-L.com. It would be my privilege and pleasure to work with you.
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