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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #176

Woman is signing a document at the table of doctor

When trying to chart efficiently and effectively, remember that keeping things to the point and concisely stated will save you time, increasing your productivity and job satisfaction.  My goal is to complete documentation DURING my visits, and 99% of the time, I meet that goal. 

Use macros or a “copy and paste” technique for phrases or paragraphs to help save your keystrokes.  

Use checklists if your EMR has them.  

If trying to chart using “bullets” like we were required to do prior to the pandemic, create templates or macros that meet the specific needs for each E & M code you’re using.  Use the least number of words necessary to document appropriately. Currently, time is the requirement for choosing E & M codes for insurance billing purposes; I have a macro statement I include in my exam notes. 

99213 is a common clinic-based E & M code, designed to include 6 “bullets” in your physical exam.  My PE looks like this b/c I am mostly a telehealth practice: 

General: fatigued, easy to engage, well-developed, NAD

Eyes: EOMI intact

Vision: acuity grossly intact 

Resp: no dyspnea noted

Station: normal

Neuro: CN grossly intact, no tremor

Psych: insight: good judgement

(you really only need 6 of these)

For billing E & M 99214, I include these so I can meet the criteria for 9 bullets in the exam: 

Mental Status: normal mood and affect and active and alert

Orientation: to time, place, and person

Memory: recent memory normal and remote memory normal

I have a macro set up for my PE; I only have to type .jgPE to populate my entire exam documentation you see above; if I notice other findings or look at a rash or other issue, I free-text it quickly into the exam.  

Charting as an NP is a completely different skill than charting as a bedside/clinic RN.  Pay attention to the minimal details you need to get across the findings you need to document.  Keep phrases short & to the point; the more keystrokes you make, the less efficient your time utilization. 

Other time-management tips: 

Use an assistant to complete some of your visit requirements, like medication reviews, allergy notes, historical data, and/or supplement use.  

Send the patient clinical data forms or links to questionnaires so they can provide some of the information prior to your visit.  

Have the patient obtain labs or other testing PRIOR to your appointment so that you can most effectively address issues and results DURING the appointment.  

Practice typing; take a typing course if necessary.  Learning where keys are without looking can save MASSIVE amounts of time.  Type during your visit. 

If your niche practice allows for you to document the same note repeatedly, set up a template with all the general info in it and use it, instead of retyping every single note.  

Build a policy of filling meds DURING visits; minimize sending orders when NOT in a visit – you don’t make money for this time spent in the chart.  I typically refill meds for the number of months until I expect to see them back.  

Practicing, planning, evaluating workflows, and adjusting as needed is vital to building efficient documentation habits.

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