Charting Mastery. Breaking down the 4 domains

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Charting mastery as a physician? What kind of unattainable dream is that? Do you realize that I spend so much time charting that sometimes I just want to sit down and cry. Notes at work, notes at home, notes in the evenings notes on the weekends. Work life balance, yeah right? I went into medicine to care for patients, not to be drowning in charting. What is the meaning of all this?

If you have had any of these thoughts or heard one of your colleagues complaining with stories and similar complaints, know that you are not alone.

Charting Overwhelm

One of the biggest threats to wellness in medicine these days revolves around charting and workflows. A 2018 study found physicians averaging 1–2 hours of charting for every hour of patient care and another 1–2 hours of charting or clerical work in the evening.

Say what? That is crazy, no wonder there are issues in the system and with wellness.

Progress, Not Perfection

Here, we will break down four domains of charting to help you move toward mastery. Lest you think you can’t do this, that you’ll never achieve mastery, be encouraged. Though I have grown a lot, I am not a master either, and my passion for improving drives me as I look to take the next step in my wellness. Take a step towards progress, not perfection.

Attending (Charting) Life

So 1–2 hours of charting in clinic for every hour of direct patient care? And another 1–2 hours of personal time doing work tasks? Sounds real sustainable right? I remember starting out of residency, and one of my colleagues told me how their kids knew they had to chart after hours, came and snuggled in bed for a bit before running off to play. I listened and thought, what in the world.

Residency was hard, finishing rounds, writing up to 8 or 10 notes. And yet, in many ways attending life is harder? Sure more responsibility, teams to lead, but charting…why does that have to be so difficult? My colleagues tell me about when it was all paper and though some things still got brought home, but mostly, it was more efficient.

And yet, here we are, aside from occasional downtimes or individual practices still with paper charting, most physicians today are doing electronic charting. And it is increasingly complex. Check this box, select from that menu, pull this in to your note. Is it any wonder these things are taking longer, that more notes are completed after hours or at home?

So what is a doc to do? There are definitely things that need to be addressed further upstream from the individual physician level, what actually belongs in a note, and though the changes to CMS documentation requirements in 2021 make some progress, they are far from sufficient. At a system level, helping develop personalized templates for departments or particular conditions can help some.

But in the meantime, with fellow physicians awaiting help and struggling under the crushing load of charting, let’s examine together the four domains of charting. The four areas to consider where we are and where we might want to go. And then, we can each take our own individual next step in our professional wellness. A quick caveat before you just turn this off as one of those “self help”, “physician heal thyself” discussions. No, the system needs reform and optimization further upstream from the individual physician. But at the same time, there are things we can each do to make things more manageable for ourselves as we work towards balance.

The 4 domains of charting

• First, navigation, getting around the chart.
• Second, orders, including labs and medications
• Third, we will go over some note tips
• Fourth and finally, we will cover messages with a related bonus topic.

Navigating the chart

First, navigation. We all have our own clinical workflows, our routines as we interact with our patients and the medical record. Depending on preferences and availability of technology or other resources, you may not chart in the room, you may have a scribe, you may chart in the room concurrently with your visit. Regardless of when you get to the computer, you will get there eventually, and then you have a few questions.

• Do I know where to find the things I need in the chart?
• Where are they?
• Can I customize the order of tabs or how things are displayed?
• What is my routine of going from one section to the next so I reduce the chances of missing something?

You may or may not have that ability to customize your views, reports, filters, or search capabilities. But if you do, this could be time well spent as you understand what your system can do. The other side of navigation involves what shortcut keys or buttons you may be able to use. They may be preconfigured or something you can program custom commands for. It could be as simple as going from the notes to orders and back or more complex, say prepopulating a message to your staff that will be routed to them on signing.

Investing time up front in these ways can reduce clicks or keyboard keystrokes, improving your efficiency and saving you time. They may also reduce the amount of times you switch from keyboard to mouse and back again, which helps your efficiency and, as we will talk about in the next episode, some of the repetitive stresses that are placed on you as a physician. Furthermore, knowing some of these navigation things can allow you to maintain eye contact and connection better if you chart in the room and potentially let you get more of your work done, whether orders or notes, before you leave the patient’s room.

Orders

So first, navigation. Second domain in your charting mastery, there are the orders. This could be labs, medications, imaging studies, medical equipment. Many of these you have to finish before the patient leaves so you don’t forget, or so that they end up on the patient’s paperwork when they leave. You can typically search for them, but sometimes they don’t have the default settings the way you want them.

That’s well and good for one or two orders, but with a bunch, it gets time-consuming, lots of clicks. It eats into to your clinic flow as two extra minutes per patient becomes twenty or more by the end of a full session. Certain orders may default the status as something to be done in the future. Others may be for the source of the blood draw. For me, in the outpatient setting, I never order an arterial blood sample, so having the defaults set to peripheral is one less click.

Customizing Orders

Ok, so you have a few ideas for customizing, now you have to see what your system supports. It may be that there are system or department preference lists that show up in a particular context to show you the most common orders so you don’t have to search for them. Maybe you get in touch with your IT or informatics team about changing some of those preference lists. You may also have the opportunity to make your own preference lists or favorites section. You may be able to set them as labs for today or a particular dose of medication with a year’s worth of refills.

Whatever it is, find out what already exists in your system, figure out what customizations you can and want to make, and then, over time, implement those changes so you can take your next step in meds and orders.

Notes and Purpose

So first we’ve covered navigation, second orders including meds, labs and imaging. But now, third, and I think most importantly, is notes.

Notes are the cornerstone of thinking about charting mastery and productivity because they typically take way more time than any other aspect of interacting with the medical record. You know that they’re important, but important for who? For you? For your colleagues and other medical professionals? For billing, quality, and regulatory entities? For medicolegal purposes?

As a physician I want to know what happened to this patient and how should that guide my current management. I also want to be able to share that with the next person to see them especially if that person is not me, so they can provide good continuity of care.

Notes and Data

And yet, notes are part of larger efforts to collect data. Many of these things can be very helpful. For instance, clinical decision support can be built into many systems as a way to remind physicians and others of something that may be clinically indicated based on the patient’s prior diagnoses.

Some data points are collected through various structures around the chart, but an increasing number of them are collected by checking a box or selecting from some sort of menu or dropdown list. The requests may start small, “just add these two checkboxes to your templates”. And yet, many of the new measures coming down from quality and regulatory entities already do, and will in the future, require more and more of these inputs.

Discrete Data Charting Challenges

It’s just a little menu, put this here for this patient, put a different one in for other patients. Don’t forget, physicians, we are tracking your progress. With moves to value based purchasing, an increasing number of physician contracts are including financial incentives for meeting particular metrics. While many of these goals and metrics are good in theory, the barriers to completion are often myriad. Language barriers for screenings that are not available for particular populations. Transportation challenges that preclude timely followup appointments to document improvement on a measure. These are the tip of the iceberg of social determinants of health, and these, too, affect quality and documentation when they have to be collected as well.

So there are challenges in how some of these data points are collected, and many of them are collected through the notes. Not only does this create efficiency issues for you and your staff, but there are also issues of how notes look to your colleagues and others. How long they are, whether that information is located elsewhere in the chart and could be marked as reviewed there, what actually needs to be in the note. Right now, look for ways to get credit for some of these things from questionnaires before the visit, from something your staff documents, or where you already review other information. It should be team-based care and quality. There may be opportunities to leverage existing workflows for some of those things.

Can we simplify the charting?

I know there are certain deficiencies with just doing paper charting, as I recently had the unforeseen opportunity to do two days of paper notes during an extended downtime. But it reminded me of my time in medical school in the student run free clinic and how only the essentials were put in the note. There were no quality checkboxes, or other things to bloat the note with. The 2021 CMS changes may allow some simplification, but I know for myself and others around me, the notes still take a lot of time overall.

Templates can help

For personal workflows around notes and charting, you will need to look at what kind of templates you have. Examine what you CAN bring into your note, what you SHOULD put it into your note and what may be reviewable on a report in the chart, what may get you quality credit without putting it in the note. Things like these. Figure out whether you want a bunch of different templates for different ages or medical conditions. Maybe just a few templates and typing in the middle to bring other things in may work best for you.

Iterative Improvements: An Example

At the time of this post, my clinic is currently working on standardizing our well visit templates for children. Another clinic in the system has already done this, and a few of my colleagues are already trialing theirs and fitting it to our workflows.

In looking at your own template revisions, there will be changes to your workflow. For some of you these changes will be small, others bigger. In my clinic, my note will likely have some things in a different spot and add or subtract other elements to suit the agreed upon template. While it means a little extra time learning where the things are, it promises consistency and efficiency gains that will ultimately help me and my colleagues. Rather than squelch the art of medicine, it should actually enhance it by getting credit for certain quality measures by having certain things added to the note more easily. It will hopefully free me up as the physician to have more time to do motivational interviewing that often adds the value, the true quality that we want to be adding as physicians.

Messages

So navigation, orders, notes. The fourth domain is messages. Those inbox messages with results, phone calls, messages from other physicians or staff. Again, some medical records have more customizable messaging options, and you could prepopulate where the message routes back to or what guidance you give. My 12 and 24-month-old patients get screened for anemia and elevated lead levels, so I have buttons that will queue up a results message to my staff to pass along to the family that I can customize before sending. Again, how can you find ways to reduce clicks and keystrokes?

There are those efficiency gains and then there are the behavioral ones. How often do you need to check the messages? For me, the notifications and habits I have formed around checking my smartphone have also increased the frequency that I check my messages. The inbox is embedded within my medical record, and it is so tempting to check between patients, quite often.

The high priority messages flag themselves differently so I can see them more quickly as I should, but I need to otherwise batch my messages. This may mean checking only a few times a day, taking care of the messages at those times when I can stay in the flow and answer a bunch of messages at the same time.

Paperwork

Which leads me to the bonus topic or domain in charting, which is paperwork. Though not on the medical record itself, there is a paper mailbox for most of us that has faxes to sign, physical forms to complete, or other requests or records for review. Checking a limited number of times per day or per week allows you to remain consistent and efficient.

Batching these also can be beneficial since they physically take up space on your desk as you review them, potentially sorting things for scanning versus things your clinical team will end up faxing. So batching works for messaging and paperwork, whether I am printing a physical form from the record as a result of the telephone call message requesting its completion or whether I am sorting that outside shot record that will need to be manually entered.

Your challenge

Navigation, orders, notes, messages, and paperwork. I leave you now with this challenge. Take one domain each week for the next month, and write out 3 things you want to change or focus on for each of the domains. Make it a specific goal, measureable, attainable, realistic, and time bound. Then, at the end of the week, write down what happened, and how that made you feel. For this first week, pick which area or domain you are going to focus on, and post it on social media along with one of the action steps you are committing to trying. Tag me @MedEdWell on Instagram or Twitter.

Future State

Now, take a moment and imagine, a month from now, if you were 5% more efficient in each of these areas, applying some of these tips and principles, what would that look like to you?

Would you actually get a lunch break? Where you could take a quick walk outside on it? Or take a lunch break and finish any additional charting so you were all caught up going into the afternoon? Would it look like making it home for dinner? For you kid’s sporting event? To get them from daycare? To have your evenings free from the stress hanging over your head? What would that mean to you, your wellness?

Commit to taking that next step in your wellness today professionally since I know from experience that gains in charting efficiency make a huge difference in personal wellness also!