Home Forums Discussions General Discussion So...how fast are you?

Okay...I've never been the fastest when it comes to documentation - I've always tried to get it nearly "perfect". As one physician commented during an audit -"I can always see the patient and tell what you are thinking when I read your notes". While that's great, the time factor is now wiping me out. I was be much faster with dictation than I am with AC. I realize a good part of this has to do with now having to do my own coding (both the icd9 and various cpt codes and the rules around that...ie will I get paid, did I put in the modifier etc)- comes with having your own practice (it's crazy making really).

This is what I do:
-Assistant puts in vitals and CC. If it's a new pt, she will also document what they have written for PMX, FmHx and SoHx (I have a template she follows). However, I often have to edit/revise based on my interview with the pt.
-HPI - basically I use this as the persons story and find that most templates don't work for this.
-ROS - I often have to edit any template that's in there...again it seems to be about their story, though a few do seem to work.
-PE - templated with just a few revisions based on the person's exam
-Assessment - dx list with codes
-Plan - I use a few templates, but find I always need to edit.

Of course, then I have to check the codes, spelling, etc.

I realize I can use DNS with AC...but it seems it kind of defeats the whole idea of an EMR/templates, etc. Yet templates can sound rather canned. I've read notes that are obviously templated and when you see the same exact thing written for several visit, well, it's a worthless record as far as I am concerned.

So how to you really use AC for documentation, get your work done in a timely manner and still have good records?

Looking forward to some recommendations....

Barbara

I have to admit for most 99213 without giving a lot of thought to labs, I can chart a note in about 90 seconds. My MA enters everything on the left side except the meds. I do add a little to the HPI which already has all the pertinent ROS. I use a template to cover all the other as long as I get 2 - 9 ROS and 4 bullets in the HPI which sets up a 99214 if I get to the right exam and decision making level. The PMH and PSH and allergies generally stay the same. I always open the meds and make sure they are still on the same which, again, they are usully one.

Yes, I do use templates for the exam. I guess I could dictate and/or use drill down EMRs like Logician, but that would take forever althouh it has the advantage of computerized coding. I personally don't see anything wrong with having the same exam documented if it is a left otitis media as long as I try very hard to make sure I document a murmur. Of course, there is always a chance I forget or miss something. I remember reading about one doctor who was documenting a testicular exam on both male and female patients.

The diagnosis is simple, and the antibiotic takes only a few seconds (if you have a good database - which I have but no one wants, lol). If I do have a lot of labs or management it takes longer, but that is usually a 99214.

With managed care and insurance companies paying less and less, we are forced to see more and more patients. I would love to dictate a three-page note like a consultant does, but they are seeing five to ten patients a day max - probably less.

Of course, I have been using AC for over three years now.

Just my experience.

Hi, I am still feeling like a neophyte when it comes to managing all the options with AC. I am slower with it than I was with our handwritten check sheet but my documentation is so much better. I am using DNS and it is a help and a hinderance but I am getting better at using it. Some days I am done when the last patient leaves but most days, I end up staying about an hour after to clean up my charting, scripts, etc.
dave

I use DNS Medical ver 7- going to get ver 9 upgrade. I agree that templates never fit quite right. It takes me about 60 - 90 seconds for a 99213.We still use a separate PMS so I write codes.
DNS does defeat the template idea but not the advantages of EMR.
You have to have the horsepower to run DNS Pentium 2.5 at least 1 gig of ram but it sure is a lot faster than typing! DNS is pricey and you have to be patient with it at first the more you use it the better it becomes.

I have thought of upgrading to dns 9 but wasn't sure it was worth the cost. It is a great help in documentation, though. My typing in general leaves a lot to be desired. Not sure how I would do if I only had to type....probablly would get better!!
dave

What version do u have? Is it Medical?

I upgraded from Medical 8 to 9 and it is much more accurate. I'm running it on a 1.8 Ghz core-duo, 1GB mem. Toshiba tablet with no problems. SpeechTechnology.com had a special price then of $99 for the upgrade (which essentially is a full version that asks for your previous serial number to activate it.) Now the cheapest upgrade I can find is BestBuy at $313. Probably still worth it, unless your old version is working flawlessly. Next I'm hoping to find a good Bluetooth over-the-ear microphone that works well with it to free me up from the cord. You might try calling SpeechTechnology to see if they can give you an upgrade deal.
PS: I make macros in Dragon 9 to populate the chart. (ie. "Male Sports Exam" "Female ROS") Seems to work faster than picking templates. And if I want to change anything, I just say "select ____" and say the new word. Sure beats mouse clicks, or worse--trackpads!

I'm using Via Voice 10 with fairly good accuracy. Has there been anyone comparing Dragon Naturally Speaking with Via Voice head-to-head? Via Voice is a lot less expensive.

I'll check it out - thanks. I agree the macros are SWEET. I use them a lot.