68. Take the Suck out of Documentation | Making the most of scribes, documenting in the room (and in front of the patient), efficient workflows
Dec 13, 2021
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This podcast discusses solutions to make medical documentation and the electronic medical record (EMR) less onerous for doctors. Topics include using scribes effectively, documenting in front of patients, and efficient workflows. The podcast also explores the use of technology like Dragon voice recognition software in medical documentation and the impact of COVID-19 on dictation. Strategies for managing devices, communicating with patients, and enhancing transparency in healthcare are also covered.
Using scribes and clear communication can make medical documentation less burdensome and help physicians focus more on patient care.
Charting in the room with voice dictation and involving patients in the process can enhance efficiency and patient satisfaction.
Deep dives
Coaching as a Tool for Physician Well-being and Career Development
The podcast host discusses his transition from being an emergency physician to becoming a certified coach and supporting the well-being of physicians. He highlights the benefits of coaching, such as forward-looking guidance, creative problem-solving, and accountability. He shares his personal experiences with burnout and the importance of having a coach during critical career stages. Coaching is described as a valuable resource for physicians to find fulfillment and improve work-life balance.
Scribe Utilization for Efficient Medical Documentation
Dr. Alan Seloff, an attending emergency physician, shares his unique approach to using scribes. He emphasizes the importance of clear communication with the scribe and establishes ground rules for accurate and concise documentation. Dr. Seloff describes how dictation into Dragon software helps in capturing the desired narrative and streamlining the charting process. The workflow involves dictating the patient encounter, including HPI and physical findings, with the scribe transcribing the information in real-time for efficient documentation.
Charting in the Room to Enhance Workflow and Patient Trust
Dr. Lon Setnek, an emergency physician, discusses the benefits of charting in the room using voice dictation and mobile apps. He highlights the importance of building trust with patients by involving them in the documentation process and reflecting back their concerns and information accurately. Dr. Setnek shares his workflow of capturing the HPI, reassessments, and discharge instructions directly in the presence of the patient, minimizing interruptions and desk time. He focuses on transparency, efficiency, and patient satisfaction as key outcomes of this approach.
Conclusion
The episode concludes by highlighting the impact of open notes and the need for physicians to prioritize transparency and trust with patients. The importance of aligning with patients, even in cases where there may be disagreement, is emphasized. The host encourages listeners to subscribe to the podcast and explore one-on-one coaching for further personal and professional development.
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 bios: Alan Sielaff is an emergency physician in Ann Arbor, Michigan. Lon Setnik is a community emergency physician in New Hampshire.
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