An excerpt from No Work After Hours: Tools to Maintain a Pleasant, Efficient, and Productive Clinic Without Work Before or After Hours.
The affected person encounter is the core of scientific doctor practices. That’s why we went to medical college from the very starting. The thrill and fervour for seeing sick sufferers and serving to them on the trail of therapeutic was an ambition. One talent set is to be a great clinician, and one other is to make sure an environment friendly workflow. I wish to spotlight some ideas for documentation, putting orders, and optimizing the digital well being report (EHR) workflow.
Documentation
Completely different physicians can have many various approaches to documentation. Listed here are a number of the many I noticed:
- Sit in entrance of the pc within the affected person’s examination room and take a look at the display whereas speaking to the affected person. Such a doctor is environment friendly, however many sufferers received’t be happy. The satisfaction scores might have enchancment, too. Steady eye contact is crucial.
- Discuss to the affected person all through the go to and doc afterward by way of typing or dictation. The sufferers listed here are ceaselessly happier, however the physicians are normally behind with their documentation and generally postpone the notes until the top of the day on busy days after they’re already behind. They’ll purpose that affected person care is extra vital than documentation.
- I noticed a doctor dictating within the examination room in entrance of their sufferers. Though environment friendly, I see it as needing to be extra skilled and interfering with the fundamentals of fine communication.
If I don’t have all the small print written instantly, I’ll overlook the small print, which is usually a massive downside. I additionally wish to have good communication with the sufferers. That’s why I like contact typing. I’ll speak to the sufferers and preserve eye contact whereas my arms are typing the notes. Typically, I would like to take a look at my display for a number of seconds, like when putting orders or renewing medicines. I’ll point out it, and I received’t be conversing then. I make my greatest effort to keep up steady eye contact throughout lively discussions.
I requested an adjustable cart and a laptop computer in every clinic to realize that. Sitting comfortably or standing within the examination rooms and dealing with the affected person throughout scientific encounters can be greatest. Many examination room designs have to have the pc arrange that approach. Generally, you’ll need to rotate your neck 45 to 180 levels to face the affected person whereas typing on the pre-installed desktop; it’s unhealthy to your backbone.
Orders
Endocrinology is a lab-heavy specialty; I can solely modify many treatment doses I handle by way of the lab outcomes. And ceaselessly, they sway my questions through the scientific encounter. For instance, if a affected person had a latest TSH of 1.5, the go to would doubtless be easy, and I’d proceed the current administration. Then again, a beforehand managed hypothyroid affected person presenting with a TSH of 30 mcU/mL could drive me to ask many questions on dietary supplements, compliance, pill colours, approach of taking it, weight modifications, and final refill, amongst a number of others. That’s why I order all of the wanted future labs through the affected person’s go to, set their time-frame for the following deliberate go to, and clearly ask the affected person to finish the labs earlier than the go to. I present particular directions on fasting standing, time of the day, and what number of days earlier than the go to to get them completed primarily based on what labs I’m getting. Collagen Sort I C-Telopeptide and Procollagen 1 Intact N-Terminal Propeptide, bone turnover markers, can take as much as 2 weeks to outcome at my establishment, whereas TSH and free T4 will take lower than 24 hours to be again. Most sufferers at my follow comply with the directions, and life is much simpler for all events. I’m completely happy to have all of the wanted information through the go to, ask all of the related questions, and have a transparent and detailed plan for the affected person. The affected person shall be completely happy to have a transparent plan after they depart the workplace.
EHR workflow through the encounter
By the point I enter the affected person’s examination room, I might have the previous be aware (for present sufferers) copied to a brand new be aware, and I might have already chosen the labs and elements of the imaging and pathology reviews to incorporate. I might additionally take snippets of the radiology photos or insulin pump/steady glucose monitor reviews and embrace them within the be aware. As I speak to the affected person, asking concerning the interim occasions and the way they’re doing, I’ll fill that within the (interval historical past) beneath the HPI.
I’ll overview the surface data for the brand new sufferers earlier than the go to. This was a tough difficulty; beforehand, it was scanned within the chart, and reviewing it was tough. Think about being solely in a position to see a web page at a time; I couldn’t scroll by way of the pages, and it wouldn’t be straightforward to travel together with your notes within the EHR. I labored laborious to replace the protocol, educate the employees, and have them connected as PDFs that I can have side-by-side with the EHR be aware. You may simply modify your display dimension by pulling the title bar down and utilizing any nook to resize it. I can scroll by way of the PDF on one half of the display whereas having my be aware on the opposite half and typing or dictating instantly earlier than the go to.
I’ll normally preserve eye contact with the affected person whereas touch-typing no matter is related as we undergo the historical past. I’ll go subsequent to enhancing the bodily examination primarily based on my findings, after which I’d normally stand by the affected person’s facet and present them what I’ve within the labs, imaging research (ceaselessly pulling the photographs), or glucose reviews. The sufferers are normally wanting to be concerned in my information evaluation and actively take part within the evaluation and arriving at conclusions. It additionally makes it simpler to agree on a shared plan.
Afterward, I edit the evaluation and plan accordingly, and I’ll kind whereas saying it out loud to sufferers. I normally begin by saying: Let me inform you what I’ll write down. You may entry it by way of the portal; I’m not hiding something. I normally write within the plan what I’ll copy and paste beneath affected person directions. I’ll order all of the wanted work-up to be completed quickly, if mandatory, and earlier than the upcoming follow-up go to, together with reconciling the medicines. I’ll finalize the directions afterward with all these particulars.
When the affected person leaves the examination room, I’m able to finalize the be aware, place the cost, and put together for the following affected person. That is the same old rule that I’ll do virtually on a regular basis. By the point the final affected person leaves, I’m completed with all of the notes and fees for that day. In between the sufferers, I am going by way of the inbox, messages, and outcomes and intention to complete them by that point.
This workflow facilitates going to the clinic 5 to 10 minutes earlier and leaving when the final affected person does. Isn’t it nice? I virtually at all times depart the workplace by that point with completed notes, fees, and a clear inbox. That’s why the clinic, particularly an endocrinology clinic, is a stupendous follow with a low likelihood of burnout. Constructing an environment friendly follow is a studying curve, and it’s one hundred pc price it.
Michael Morkos is an endocrinologist and writer of No Work After Hours: Tools to Maintain a Pleasant, Efficient, and Productive Clinic Without Work Before or After Hours.
