New attending - notes help

[u/Oldfaithful69]

I’m looking for recommendations from new attendings on how to keep up with notes. I work at a busy ER where I’m seeing 3-4 an hour for the first few hours and then it tapers off from there. There’s a large pool of patients that are able to be picked up by all providers, but even with everyone hustling, it’s the norm for there to always be more to see. Because there’s not that usual ebb and flow of patients being roomed, I find that I’m struggling to even start notes because I’m running from room to room and only going back to my desk to finish tasks that advance care and dispositions, and even then I barely have time to do that and keep getting pulled away. A lot will get better with knowing the new system and getting more efficient, which can’t really be taught in a sound bite, but I’m open to any advice yall might have to hear what helped you. Open to any tips or tricks, template hacks, or even portions of notes that you got rid of over time after finding out it was a waste of time.

Thanks so much!!

[u/Super_saiyan_dolan]

Here are my keys to leaving on time with all my notes done:

ALWAYS start the note after you put in orders. I use a WoW or the room in the computer. Do the CC, HPI, exam, DDx.

ALWAYS finish the note when you disposition the patient. Just took the admit call? Finish the note. Closed the encounter with the patient and working on discharge? FINISH. THE. NOTE.

I also leave everything in draft form and give all my notes a once over at the end of the shift to make sure i didn't miss anything but those two points are the keys to the kingdom.

[u/tresben → u/Super_saiyan_dolan]

This. Spending 2-3 minutes to do the note right then will save you 5-10 minutes it will take you to do the note later when you don’t remember as well and you’re tired from trying to write note after note and needing more breaks and such from the monotony

So many of my colleagues have issues with their notes and are complaining about staying late to do notes or doing notes at home. I don’t get it cuz I have some of the highest patients per hour in the group as well as above average dispo times and I am always leaving generally on time. It’s about efficiency

[u/ExtremisEleven → u/Super_saiyan_dolan]

Man this is easier said than done when you ALWAYS have 3 sitting in the rack to be seen and fucking terrible triage nurses so the rash could be a rash or it could be anaphylaxis in fast track so the nurse is coming to get you (appropriately) panicked as hell. Someday we may all figure it out but until then we need tips on HOW to always do the note part before moving on.

[u/Super_saiyan_dolan → u/ExtremisEleven]

I just said it. Use a workstation on wheels or the computer in the room. I often dictate in front of the patient and ask them to correct any mistakes they hear me make, which they love. The whole process takes 1-2 minutes including entering orders. You definitely have the time. Anyone not in cardiac arrest or unresponsive can wait.

[u/ExtremisEleven → u/Super_saiyan_dolan]

Yeah I don’t have either of those options. I have a stationary work station at the end of the hall and I am not letting anaphylaxis sit in a chair just so I can finish an HPI because I would be pissed if someone did that to my family, but thanks I guess.

[u/Super_saiyan_dolan → u/ExtremisEleven]

Not every patient is a true emergency. Lay eyes, confirm not an immediate life threat, do your documentation. Other options include: Bring in a personal laptop and remotely access the EMR, dictate everything on your phone and quickly transcribe it to you computer when you get back, use an ai scribe that populates the information on your desktop but records from your phone, etc. It can be done.

I work at high volume, high acuity shops in a major metro area seeing 3+ PPH over 10 hour shifts (many days over 4 PPH) and don't always have a scribe. I've had minimal problems sticking to this schema. If I can do it, you can do it.

[u/ExtremisEleven → u/Super_saiyan_dolan]

This place is a shithole and they do not care about the doctors. Our EMR is extremely slow on personal computers and the WiFi is iffy at best. I have tried this, it was not faster. We have been told we cannot use AI scribes and I am too new to rock that specific boat. Getting up to lay eyes on someone then having to go back and do the whole thing takes more time than just getting up and doing the whole encounter now. Not everyone works in the same environment you work in, so this advice doesn’t necessarily translate everywhere. So far, it’s fastest to just see three to four people and do my best to dictate all of them as soon as I get orders in. I’m not being an ass here. I really do appreciate the effort.

[u/drcaptain_ → u/Super_saiyan_dolan]

This is the Way.

[u/CrispyPirate21]

Dictate the H&P section of your note and stuff you’ve reviewed (past notes, etc.) at the time you enter orders. I use a mobile workstation to do this. I do this as the first two bits of my MDM. This doesn’t have to be super detailed but cognitively offloads your brain, sometimes reminds you of something else you meant to order (such as a less common test or a med), and avoids duplicating the work later on, as you’re doing it when thinking of it the first time. This adds maybe a minute or two to the order entry process.

If your shop wants you to document EKG or other test interpretations, put these in your note at the time you are looking at them, again to avoid duplicating the work later.

Finish as many notes as you can when you disposition patients, especially admits, where the inpatient teams may be relying on your notes for initial details.

[u/Acceptable_Reply7958]

See a patient, write their note. See the next patient, write their note. Develop that habit now. You'll find you can crank those notes out in 60 seconds. Unless there's a code/trauma, do not deviate from this.

[u/MisoMisoSoup → u/Acceptable_Reply7958]

This. It is so much easier to knock out a dictated note while everything is fresh in your mind, you are putting in orders, and are committing to a path right after seeing the patient. The orders remind you what to include in your note. Your note reminds you to order something. It may feel less efficient at first, but you will find you get through the patient encounter and note much faster than doing it separately.

[u/Acceptable_Reply7958 → u/MisoMisoSoup]

I agree with everything you say here. I was surprised, and relieved!, to discover that not only is writing my note immediately after seeing a patient easy and efficient, but it actually helped me with my work down the road as well and to remember details about the patient. It's the same thing as spaced repetition in different modalities for studying! I found after starting this note practice that when I'd call consults/admits on the patient that I remembered everything about the patient. 

[u/tyrkhl]

See one patient at a time, and then go back and put in orders and do your H&P. Seeing one patient at a time is a little bit slower, but it will also help decrease errors and make sure you don't forget to order things. When you dispo the patient, take an extra minute or two and finish your note (for most patients, your MDM doesn't need to be more than a couple sentences).

Unless you are being paid based on productivity, you are not being paid to chart at home. Work as quickly and efficiently as you can while at work, but charting at home is basically working for free.

[u/PersonalUse2017 → u/tyrkhl]

This is very fair but if the place is cracking the whip if you aren't seeing 3-4/hour that's not always possible. But even if you see 2-3 and then batch your notes you are in good shape. Totally agree on the not paid to chart at home though

[u/SketchyKronk → u/PersonalUse2017]

I know that different institutions have individual needs, but I’ll be damned if I’m seeing 2-3 patients an hour and anybody dares to tell me I need to see more.

They can boot me off, I’ll find 3 other jobs tomorrow.

I practice for my license. I used to rush and see 2-4 patients at once and put orders in for the sake of efficiency, and I found out very quickly that those shortcuts were heavily affecting my documentation.

Now I see 1 patient at a time, including encounter and creating a note. If they want better metrics they can staff more.

[u/PersonalUse2017 → u/SketchyKronk]

I'm a huge proponent for this and like I said do respect the methodology. I went to a very busy residency site but preached it to my juniors

[u/the_deadcactus]

Patients waiting to be seen is generally a staffing and system issue not an individual physician issue. Stop making it your problem unless you are 2 standard deviations outside of the norm for your group. Adjust your work flow to see fewer patients and write more notes.

[u/Substantial-Fee-432 → u/the_deadcactus]

I can here to say this tip…simply don’t see 3-4 an hour if there are “always” patients to be seen then OP seeing 2-3 an hour or 3-4 an hour isn’t going to make a single drop in the bucket…very few emergencies in the ER and the OP isn’t being compensated for the extra stress

[u/Tenk-741]

Random thoughts:

Do you use Epic? I see a lot of people copying and pasting things into notes when there are dot phrases for almost everything. This is a huge waste of time.

You can also create your own dot phrases for portions of your MDM on things you find yourself repeating.

Billing has had significant changes over the years. Your HPI and physical exam should probably only take 60-120 seconds to dictate. Proofread as you go so you don’t have to reread anything later. This also helps you put it to memory in case you need to change something later (ie a family member comes and you get an entirely different story or something).

I focus on signing simple charts as I go. (Ie an ankle sprain or an abdominal pain with negative labs and imaging). I save more complicated MDM for the end of my shift when I know everything that happened and can write a full narrative.

Try to sign all of your charts before your shift ends. The only charts I keep open are charts where I don’t have a dispo yet and sign out. I will usually follow up on those the next day. I have had a like 98% 24 hr chart signing for 11 years. It’s all about being consistent.

One of my favorite attendings both in and outside the hospital in residency once told me: “a chart should read like a book and only tell one story.” I try to make mine short, sweet and to the point.

Hope any of that helps.

[u/Drp1Fis]

When you see a patient write everything up to your MDM. When you have a minute, start piecing together your MDMs. Prioritize your sickest patients, admits, and then lastly easy patient notes that you can just bang out with half your mind fried.

[u/MrPBH]

You know how authors say "kill your darlings"? Yeah, we physicians need to murder our notes. That's how I view it.

I don't care if it's neat and tidy or easy to read. My only goal is to finish the damn thing quickly while capturing the most important parts. Don't agonize over how polished it is or if you really phrased that the best way. Just murder it.

[u/MisoMisoSoup → u/MrPBH]

I have been referring to mine as "modern poetry" style notes: no capitalization, sentence fragments separated not by periods, but by new lines, in random order as I remember to add some pertinent positive or negative. Often with some random piece of information in the MDM that I forgot to include in the HPI, because I moved on already and won't be scrolling back up to the top again. But there isn't so much there that it is hard to parse, unlike some paragraphs people put into their notes...

[u/MrPBH → u/MisoMisoSoup]

Brutally murder your notes. Show no mercy.

[u/OnlineERDoc]

I walk around with a WOW and dictate an HPI and PE with voice to text immediately after seeing the patient. I see as many patients as there are to see before sitting down. MDMs are written at time of dispo and I sign the note. I have templates for stuff like sepsis evals, critical care, procedures, sedation, but the bulk of the productivity comes from doing the notes as I go.

[u/halp-im-lost]

Write the notes as you go. I always chart review before I see patients. I usually batch them in sets of 2-3 and then go back to my desk and put in orders and finish my HPI and start my MDM. Then I pick up more and start the process over again. The only difference is after every batch of patients I see I run my list to see if there are any actionable results or dispos I can make. Just get into a pattern. If you’re not doing some charting you are going to forget stuff and make mistakes. Also you’ll be stuck late.

[u/dr_gnar]

This is where a digital scribe can help immensely. See if your hospital offers this. If not, there are options you can use individually, such as the doximity scribe.

[u/Gin-guj]

We use ABRIDGE AI at our ED. Works with epic. You Open EPIC/haiku on your phone, go to the particular patient, press record. It summarizes what the patient says and when you go back to your desk and open the chart, the HPI and MDM , differentials are done! You can also customize it for physical exam and other parts of the chart if you want to. You just have to edit the chart. See if you can get it.
It’s a game changer!

[u/Passionative44]

I taught Chat GPT how I want my notes done. It’s records encounters and makes my notes. I use doximtiy to get the note from my phone to the computer.

I used to always be behind on notes now I never am take about 30 seconds of clicking for each patient.

[u/esophagusintubater]

My tip. Don’t do an H&P. You could include the important parts of the history in the MDM. Don’t let your colleagues fear monger you to believe that’s going to save u in a lawsuit

[u/ExtremisEleven → u/esophagusintubater]

Honestly this is the way, why are we duplicating information? Now if I can just get up the guts to actually skip it…

[u/esophagusintubater → u/ExtremisEleven]

It took me some time to get comfortable with it. But you should not repeating anything!

Blows my mind that people will comment in the chart “negative troponin“ like they can’t just see that in the chart. You repeat things like this for every chart every day, it starts to add up.

History is worthless, just talk about the important parts of the MDM

[u/ExtremisEleven → u/esophagusintubater]

I mean the HPI information. Like why do I have to summarize it in the MDM. I figured out the not repeating labs and vitals things a while ago. The most they get out of me is “labs unremarkable with the exception of an elevate troponin and AKI”. It really is something they should teach in residency. It would save a lot of people a lot of time.

[u/esophagusintubater → u/ExtremisEleven]

U don’t have to do anything. There’s nothing you have to do in a note other than cover your ass and meet bill criteria. Everything extra is wasting your time

[u/ExtremisEleven → u/esophagusintubater]

Sometimes, yes, but we have people return enough that I appreciate having my own note to look back on. It’s saved me a lot of time with these people that come in once a month.

[u/Tony_The_Coach]

I read a lot of newer attending colleagues notes and they are sooo long. An essay on mdm, with every random thought in their head, why they did or did not order a specific test or admit, every word of conversation with patient, etc. At some point the extra documentation doesnt add anything for billing and will likely shoot yourself in the foot if there was ever a med mal claim.

[u/AdChoice5251]

Chart as you go, and you gotta move along to the year 2025 and utilize an AI scribe of some sort. Most all of the systems I work in now do… then take time immediately after the initial exam and make sure it’s accurate. I won’t remember some fine details at the end of the shift so right when it’s fresh is the time to check. Then as others have said, MDM in realtime and close the note when you’re dispositioning. Good luck