How do you get through 35 charts by the last pt? I put the essential details in the chart when I am w/the pt and then chart for 1-2 hours after the kids go to bed. I had 105 messages in my inbox at 6pm today!! Spent 20 minutes going through all the messages making sure I had not missed an important message or lab that had to be addressed. I planned on charting tonight - but the comcast router dropped the internet and now I have no Logmein access!! SO why did we go paperless- - At least w/paper charts, I could write incomplete sentences and get away with it and be done charting by now!!.
My workflow must be very wrong!!
I would agree with Leslie. Look at what needs to be written vs modified templates. First, if the MA can do some of the background work, that's much less you have to do.
I have my MA write a hx of CC in the HPI and I then will add comments or sometimes a complete HPI.
The MA will have updated the ROS and SH if relevant.
The PE is carried over from the previous visit or I add a new template and modify the changes.
I then put in the dxs and template the plans or write Rxs. If immunizations need to be added the MA's do that.
I will sometimes change the plan template to review what should be done and may check a box if appropriate. All of this takes less than 5 minutes. I am usually talking as I type or sometimes listening.
Some of it is practice, some of it is the ability to type without looking. My desk is usually sideways to the parent, so they can both see what I am doing and it is easy for me to look at them and type. Usually I talk and examine and then will "look over the numbers" and start the charting. I continue to ask questions and give answers while I am typing. Some of my templates are to give reminders on questions to ask, some are just the necessary verbage and then I will modify as needed.
Everyone has their own style, you have to develop yours.
