The art of the chart: 10 tips that help me never chart at home

This response really got me thinking. I agree! Is this the “new normal?” I can’t help think that this is a recipe for disaster. Career dissatisfaction. Burnout. 

But why would there need to be charting, phone calls and requisitions done at 10:00 p.m.? There must be a better way. 

I am a very busy physician who is fully booked on clinic days. My last patient is booked at 4:45 p.m. and I rarely leave after 5:30 p.m. I leave with all my charting done. All of my phone calls done. ALL of my paperwork done. I am sleeping soundly, not charting at 10 p.m. every night. 

Read: Is alcohol the new cigarette?

That’s impossible you say! Well . . . I have been doing it for years and it works for me. 

Tackling the entire world of administrative medicine might be beyond the scope of this article so let’s focus on the EMR. This is generally what makes or breaks us when it comes to “charting” at home. 

I fondly remember doing a locum for a rural family physician and seeing his documentation for annual medical exams for his patients. “CPX” for men and “CPX with or without PAP” for women. That’s it, that’s all! Horrible documentation by a questionably competent family doc by today’s standards. Not what his patients thought and said. They clearly loved and adored him for his life long dedication and meticulous care of them and their families. 

Alas, those were simpler times . . . 

Chart note circa 1980:

“Dx tonsillitis – T/S done, Rx PenVK” 

Has morphed into circa 2022:

S – 4-day history of increasingly severe sore throat. Febrile with temperatures ranging from 38.0 – 38.8. No obvious respiratory symptoms noted. No runny nose, nasal congestion or cough. Complaints of swollen glands bilaterally. Unsure if contact with strep. Colleague had similar symptoms and they believe might have been diagnosed yesterday with strep throat (unconfirmed). 

O temp 38.5. Looks ill. TM’s N, examination of oro-pharynx reveals enlarged, red and exudative tonsils. Bilateral cervical adenopathy noted. Chest – good a/e bilat with no adventitia. 

Centor score: 4

Throat swab completed and will be sent today

A Presumptive Streptococcal Tonsillitis 

P Rx given for PenV K 300mg qid or 600mg bid x 10 days. Given score can start immediately or wait for throat swab result to come back if patient wishes– expect turn around in 24 hours and patient can call back re: result. Ongoing symptomatic treatment with gargles, acetaminophen/NSAID for fever. Watch GI side effects if using NSAID. 

If persistent symptoms after course of antibiotic, patient needs to call back or if there is distinct progression or deterioration—call Health Link or go to urgent care. 

We’ve turned a simple presentation into a beautifully written novella. Yes it would absolutely stand up in court. Bravo! 

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Care and patient experience in both scenarios—identical. The real difference? Charting complete in room (not onerous) vs. charting complete only at home at 10 p.m. 

This is merely an example and we could debate the medicine (i.e. does strep throat actually need antibiotics?) but that is not the point. The point is, we believe, we are told, we are medico-legally being threatened with the idea that we have to document each and every detail of encounters. And that takes time. A lot of time. Or does it have to? 

In the above example, we could have a check off STAMP or MACRO on our EMR so that all is there and all we are doing is checking off boxes to get to the same place, with the same precision and detail. Or we have a cut and paste template for “Tonsillitis” which incorporates an excellent and complete note from which we cut and paste the details that apply. Either way, we have excellent documentation, which is necessary and appropriate, at a fraction of the time.

After 35+ years of medical practice, here’s how I have managed NOT to chart at home. WARNING: I cut my teeth on paper charts, so I am NOT terribly tech savvy. But even I have had good success once I took ownership and refused to accept the status quo. Some of my peers are much more advanced and sophisticated in their use of the EMR as a valuable tool and not a noose around your neck. Lots to learn from them. 

MY TOP TEN RULES:

1. Always chart as much as possible while in the room with a patient. No time like the present. 
2. Never hand write notes and then transcribe to chart, everything directly on chart. Always, with no exceptions.
3. Finish off your charts as much as possible before you leave the room. Even a minute goes a long way. 
4. Finish off your charts as soon as possible in between patients. Even a few seconds goes a long way. 
5. Write less, be succinct. Focus on assessment box of SOAP note and be very precise in this. Ensure the crucial details are captured and worry less about the superfluous details. 
6. Use stock templates whenever possible. Anything that you see in repetition could become a stock template in the future (and save you time) 
7. Template your lab requisitions, template your forms, template any requisitions. Template everything you possibly can. This improves consistency and time efficiency. 
8. Make up handouts or compile web links and use them. Charting the exact same things over and over is much less efficient than saying a specific handout was given (attached) and explained.
9. Have your staff/a dedicated staff member fill out as much on any paper work/form as possible. The more they do, the less you need to do. A lot of time is spent sorting out dates and details (all of which administrative staff is more than capable of doing). 
10. Email messages, phone messages, any communications are all answered same day with brief succinct answers, which are all charted. I answer and my staff deliver the message. More questions, then a visit will be needed (period). Patients learn very quickly and communication becomes very efficient. 

The only chart notes I make are to answer messages and on virtual visits. Everything else I do is dictated/transcribed and is comprehensive and extremely efficient. I use stock template paragraphs on all of my visits—initial consults and follow-ups. I customize and add pertinent details to this base. My documentation is superb, accurate and takes very little of my time. 

Did I say I don’t do any charting after 5:30 p.m.—ever! 

Dr. Ted Jablonski is a singer-songwriter, emerging playwright and neophyte poet who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta. He now finds himself advising medical students at the Cumming School of Medicine and still on the front line trenches of acute medicine in primary care.