68. Take the Suck out of Documentation | Making the most of scribes, documenting in the room (and in front of the patient), efficient workflows

Nobody goes into medicine hoping they can have a long career in data entry, but that’s how many feel when looking at computer screens more than patients during a work day. Documentation and the electronic medical record (EMR) are nearly ubiquitous sources of frustration in medical practice. In this episode we cover two solutions to make medical documentation, charting, and the EMR less onerous: a very specific way to interact with scribes and using technology that’s already in your pocket to chart at the bedside. These might seem like ‘tech hacks’ but they are really tools to get away from the computer and back to patient care.

Guest bio: Alan Sielaff is an emergency physician in Ann Arbor, Michigan. Lon Setnik is a community emergency physician in New Hampshire.

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We discuss:

Challenges that scribes have when documenting critical parts of the medical record [08:25];

Scribes clearly add to the efficiency of the ED workflow, but they do not have the same level of training as the physician or APP when it comes to creating the narrative.
We spend a lot of time training our minds to be able to tell the story in a chart that essentially becomes an argument for medical decision-making. There are pertinent positives, pertinent negatives, and certain ways that our thoughts flow to explain things.
To those without years of training and experience, extraneous information sounds just as important as vital information. All of these factors can combine into the perfect storm when a scribe does your charting.

Setting ground rules with your scribe [09:30];

At the beginning of a shift, Sielaff lets his scribe know what he does/doesn’t want in the chart. For example, he doesn’t want every radiology report copied and pasted, or every lab pulled in. More often than not, he addresses those things in the medical decision-making portion of his document. If there’s something specific, he will ask for it to be pulled in.
Sielaff reviews (with the scribe) chronic active conditions that are automatically populated with his charting system. Some of these auto-populated conditions might need to be taken out of the chart to make it look presentable and appropriate.

The provider-scribe workflow [11:20];

Sielaff does not take scribes into the room during the history and physical exam. Upon exiting the room, Sieloff dictates the HPI, pertinent physical findings, and the beginning of the medical decision-making directly onto the scribe’s computer. The dictation is done by voice recognition (he uses Dragon Pad) into a temporary holding document.
Sieloff uses his own computer and workstation for reviewing old records and imaging studies which he can selectively import into his document as he deems appropriate.
The scribe then proofreads and adds the dictated information into the chart while Sieloff sees the next patient.
This method protects the scribe from having to interpret ‘patient speak’ and allows the provider to be precise in the language used and narrative created. Since there are many nuances of targeted history-taking, it is the job of the provider (not the scribe) to delineate what needs to be addressed at the visit and how critical elements should be documented.

Lon Setnik’s tips for successful utilization of scribes [19:45];

In Setnik’s institution, the people who were most successful using scribes were those who were able to examine their own workflow and change it in order to optimize the scribe’s work, not their own work.
Setnik asked his scribes to document his verbal summary and reiteration of the patient’s history (he did this in front of the patient), rather than having them document as the patient was speaking. This way, the scribe performed the function of capturing the information that he thought was most valuable.
The HPI isn’t just a transcription of the patient’s words. It’s our interpretation of the patient’s history.

The importance of doing as much of your documentation as possible in the room with the patient [24:35];

Setnik now uses voice dictation rather than scribes, but he still finds it important to do much of his documentation in the room with the patient. By dictating the patient’s history in front of the patient, it gives the patient the opportunity to make corrections and it gives himself the opportunity to ask clarifying questions. This saves time and leaves the patient feeling as if they were heard and understood.
He tries to complete the history, physical exam, orders, discharge instructions, and medical decision-making as much as possible in the room.

The strategy of dictating the chart in the patient’s room requires several enabling technologies [26:00];

You have to be able to log into the workstation quickly.
Your organization must have the ability to have a “thin client”. In other words, you need to be able to open up your workstation to whatever window you were on for that patient last.
Setnik uses the Dragon PowerMic mobile app on his cell phone which functions as a dictaphone and serves as a virtual transcription device.
This method is much more difficult (if not impossible) in the era of COVID-19. It also doesn’t work well in the context of multi-trauma or other cases where there are numerous providers in the room.

The primary advantages of documenting in front of the patient [33:05];

It builds trust by adding transparency to his work process.
It adds efficiency, because there are fewer times that you need to go back and forth into the room to get additional history.
It reduces his cognitive burden, since you don’t have to carry so much information around in your short-term memory.
It increases the amount of time you’re spending with the patient, rather than with the computer.

Habits for good workflow discipline and documentation [37:15];

When first entering the patient’s room, don’t go to the computer first. Start with an open-ended question and hear the patient talk. This is the most efficient way to gather information.
Try not to do work twice. Instead of taking notes on paper while the patient is talking and then going back to enter it in the computer, whenever possible put it into the computer immediately.
Always try to do an item of work as one piece, rather than a multiple of smaller fragments.
If possible, give the patient discharge instructions with the nurse present. This dramatically expedites discharge.

A primary goal in caregiving: building trust with the patient [42:00];

Trust and engagement largely come from humility, and openness. Trust requires that we be fully transparent in what we’re doing and thinking.
Technology and workflows are enablers for our ability to work in a way that builds trust with the patient.

And more.