An effective charting process is important for physicians because it helps them get more out of their work. Your input and those from other stakeholders need to be recorded in the notes. This makes easy documentation and charting efficiency crucial in creating a congruent, transparent, and flourishing system.
There are so many things that you can do as a physician. Some you can implement yourself, and others are outside your control, but you can advocate for them. However, to create quick wins for you, your patients, and your critical team, focus more on what you can change.
Join the conversation with your host Dr. Ryan Stegink as he shares more on medical charting, why, where, and some of the things we need to change to improve efficiency in clinical workflows and, ultimately, wellness for medical teams.
During this episode, you will learn about;
[00:01] Introduction to the show
[01:52] What in for you in today’s episode
[02:37] Investing in family by applying lessons in episode 34
[03:34] Making a difference for you, your patients, and your critical team
[04:21] Dr. Ryan’s experience with charting in residency
[06:00] Why charting, what it entails and what it is for
[07:30] The what and where of charting
[09:56] What we need to change to flourish and increase efficiency
[12:01] How to shift your mindset around charting
[13:10] Take the next step and get things done in a way that allows you to take care of yourself
[13:48] Ending the show and call to action
Want to get home sooner from clinic or the hospital? With all your notes and charting done, too? Get your FREE PDF guide with 10 tips to maximize your clinical efficiency! https://mededwell.com/efficiencyguide/
Notable Quotes
- Thinking and action go together
- You get to choose to make a difference in the things within your control
- You don’t need to have perfect notes; sufficient notes are enough!
- There are challenges around automation, but it needs to happen because we need to make it easy for documentation
- The biggest thing within your control is your mindset and how you think about charting.
Connect With Dr. Ryan Stegink
Website: https://www.medededwell.com
LinkedIn: https://www.linkedin.com/in/mededwell
Instagram: https://www.linkedin.com/in/mededwell
Facebook: https://www.facebook.com/mededwell1
YouTube: https://youtube.com/channel/UC_6svH-LEDhLjqD7bKa2TSQ
Above are the episode show notes and below is the transcript. Some episode transcripts have been edited more than others, but they are up in the meantime to help those who would rather read and for searchability on the web. Extensive editing has not been prioritized as I seek to both produce regular content and maintain my own wellness. See the website disclaimer if you have questions, since this is all for your education and entertainment only. Enjoy!
Transcript
Have you felt exhausted in medicine? Like your practice is more like a treadmill than truly a calling? Is the charting weighing you down? Working well past your last patient of the day, charting at home, in the evenings and on weekends. The notes and paperwork, lab results, quality metrics, all the things, right?!?
What if I told you there were some ways to make a change, to get more efficient so you can finish work at work and have the margin to intentionally choose thoughts and actions consistent with your values and priorities? You can get my free guide with 10 tips for getting work done at work more efficiently. Get yours today at www.mededwell.com/efficiency
After that, if you know that you want to take a deeper dive into your thoughts and clinical practice, check out MedEdWell coaching with Dr. Stegink. Fight burnout and moral injury. Find fulfillment and create margin by examining your thoughts and actions to take that next step forward from where you are to where you want to be, aligning your actions with your priorities. To find out more and to book a consult, head over to www.mededwell.com/coaching.
You can also find that link in the shownotes of the podcast player you are listening on right now.
And now for the rest of today’s episode.
Thank you so much for joining me here on episode 35 of the MedEdWell podcast. Today, we’re going to be talking about medical charting, how the, why, some of the things that need to change. And it’s gonna be the first of six episodes focusing on clinical workflows to help efficiency and ultimately wellness for you and others on the medical team. Before we get into the rest of today’s episode, though, I want to thank you for listening, subscribing and for sharing these episodes and for all your hard work, caring for patients, I’m super excited to be back with you after my time off for paternity leave. And it’s really been cool to look back and see how I’ve been able to invest in family and apply some of the lessons that I’ve talked about here on the podcast. Looking back episode 34 was entitled thinking must lead to action in life and in medicine.
So I’ve been able to put that into practice by taking care of my family, but we’ve also figured out housing for the coming year and I’ve started doing coaching and it’s been great to see how the thinking and action that go together more on that to come. But it’s just an exciting time. And I look forward to hearing from you how you’ve been putting these things into practice. So today we’re gonna be covering charting in medicine, more generally looking at some of the stakeholders, what charting currently entails, and a few things that could help move things forward, both at a personal and to a certain extent at a system level. But ultimately you get to choose to make a difference and the things that are within your control, some of the things outside your control may be worth advocating about. But right now I want you to be able to get those quick wins and they may be longer term things, but ultimately, it’s you making a difference for you or your patients or your clinical team?
So in residency, I was often a little bit slow, particularly on my charting, as we talked about, I’m a thinker and it would just take me some time to really process. What is the patient telling me? What kind of questions do I need to ask? How do I present this and get everything done? This was especially true. When it came to the charting, I was a really good student in school growing up, and I wanted to do my best in charting. A lot of times sufficient. It’s just fine. So in my resident clinic, I had one half day a week, I would see about three to six patients still took me a while to get the notes done. And yet I graduated and jumped into being in attending and would see 10 to 13 patients every session for initially nine sessions a week that was full time.
Maybe you’ve just had a long day of clinic or been on the wards and you’re ready to go home. Except for all that paperwork charts to complete, you can stay late, do the notes at home or add them to the ever growing to-do list or tomorrow, if this has ever been your experience, stick around as we dive in a little bit more on some of these things. So first why charting, what’s it for? There are a lot of stakeholders. Sure. There’s the patient care communication with the team? A lot of times I’ll see patients, my colleagues I’ll see my patients, patients may move and transfer to a different system. There’s a huge variety. It provides some of that continuity. There’s also quality measures, regulatory, medical, legal purposes. And even the patients themselves, they can get access through the portal. And various legislation has made that part of transparency.
That really is beneficial. Certainly there’s some ways in which that works or as new challenges that we address, but some of those are opportunities for us to, to learn and to grow and to empower our patients. However, one of the biggest things for charting is to support the billing and we all know it, all those things that we have to include. Some of it’s just how it is, but then it comes back to what’s amazing and what’s sufficient. So from there we have why charting now to the what and the, where of charting previously, some of these things were a lot easier on paper. Most are using some sort of electronic medical record now, and that makes it in a certain sense, easier to collect or to require more data, more metrics, more quality measures. And all the stakeholders have some sort of input what needs to be there in the notes.
But often the staff and the physicians are the ones actually doing most of the documentation. Certainly some of the CMS changes from 2021 decreased some of the documentation requirements. However, the quality, the billing, the regulatory metrics continue to increase. When I see this, I ask, okay, we’re adding this. Is there something we can either take away or make more efficient? Because ultimately there is still the same amount of time. And though sometimes time is how you think about it and your productivity, but it’s still finite. You can’t do all the things and just keep adding onto it unless we’re gonna provide some support. Sometimes there’s discreet data that needs to be collected to make it easier to say, did the patient receive this? Were they counseled on that? Some of these things may require some sort of manual checking of that box selecting from that dropdown list.
But some of these things, the computer already knows. It just has to be automated. Certainly there are systems, investments and challenges around that, but it just needs to happen because we need to make it easy to get those things documented. So first why charting second? The what and the where of charting, but third, what needs to change? What needs to change for flourishing and for an increase in efficiency. Some of these things are things that you as a physician can do yourself, but some of these things are system things that need to be advocated for than implemented at that system level. The first thing is charting in the room, whether there’s computer workstation, that either you bring a laptop or there’s a desktop already in the room, trying to complete as much charting as possible in the room can be really helpful. It’s also important to collaborate with your staff, not only understanding what’s going on with the patient, what you can know in advance and maybe plan for maybe they are even empowered to start the note for you. It could be that you have a dictation device. Maybe you’re able to have a scribe. Maybe you’re not, but it could be something that if you can make the business case for it, we talked in a previous episode about coming with your data to make your case, as you advocate for yourself next, using
Templates and text expansion. If you type the same thing over and over, maybe you can type a few characters and it’ll bring in your typical counseling on a particular condition. The system level, one of the biggest things is that automation of the data collection, because it just needs to work more smoothly that you can provide good patient care, but also be able to care for yourself. The biggest change, however that’s within your control is in your mindset. How you think about charting, because when you hear charting in medicine, it leads to particular feelings. And they’re usually not positive ones. At least they weren’t for me for a really long time. And it’s still hard to think, to think about this in a way that says, no, I am empowered. I am a good doctor. I take great care of my patients and I take great care of myself.
Some of it is saying I don’t have to have perfect notes. Sufficient notes are fine. Let some of those thoughts sit with you. How would you feel if you could truly say some of those things to choose those thoughts it’s worth thinking about because ultimately your thoughts need to your feelings need to what you’re gonna do about it. I’m saying this from a place of having been there too, and still am, am at times I wanna encourage you take that next step to consider how charting in medicine can support you, getting things done in a way that still allows you to take care of yourself, to take that next step today. And I look forward to hearing how this has impacted you. We’ll be going deeper on some of these things over the coming five episodes. So come back and join me as we consider how to support wellness in medicine. Thanks so much for listening. I appreciate all that. You do. Please take a moment and share this episode, share it on social media, text it to a friend. I really want to be able to support physicians to be able to support you as individuals, as physicians and as people, if you’re looking for tips on how to implement some of these things, check out my free guide at www.mededwell.com/efficiency has the 10 tips and many of which we’ll be going over in the coming episode. Thanks so much for all you do. Have a great day!
And now for our important disclaimer:
Dr. Ryan Stegink is a practicing general pediatrician, but the MedEdWell podcast does not reflect the views, opinions, or beliefs of his employer nor affiliated university. Additionally, the MedEdWell podcast is for educational and entertainment purposes only and should NOT be considered advice regarding financial, legal, student loan, medical or any other specific topic. In such a case, you should seek consultation with a certified professional in that particular area. Again thanks for joining us on the MedEdWell podcast, and have a great day!