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

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Dec 13, 2021

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.

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Introduction

00:00 • 4min

Strategies for Effective Electronic Documentation

04:09 • 10min

Using Dragon for Medical Documentation and Chart Completion

14:01 • 2min

Different Workflows for Documentation

15:36 • 10min

Enabling Technology for Efficient Documentation in the ED

25:32 • 5min

Managing Devices and Documenting Patient Instructions

30:10 • 15min

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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For full show notes of this episode and all sorts of other goodies, visit our podcast website

We discuss:

Challenges that scribes have when documenting critical parts of the medical record [08:25];
Setting ground rules with your scribe [09:30];
The provider-scribe workflow [11:20];
Lon Setnik’s tips for successful utilization of scribes [19:45];
The importance of doing as much of your documentation as possible in the room with the patient [24:35]
The strategy of dictating the chart in the patient’s room requires several enabling technologies [26:00];
The primary advantages of documenting in front of the patient [33:05];
Habits for good workflow discipline and documentation [37:15];
A primary goal in caregiving: building trust with the patient [42:00];
And more.