UPDATE: As of January 1st, 2021, there are E/M changes to outpatient services that will base billing on total time spent on, or medical decision making based on, the encounter. (POST ON THIS COMING SOON)
THE GOOD NEWS: Your PRE-CHARTING, other preparations (reviewing related topics on Up-To-Date), face-to-face time and post-visit charting are all counted towards total time spent and can be billed for accordingly.
THE CAVEAT: The total time spent, including PRE-CHARTING, on the visit is only valid if occurring on the DAY OF the actual office visit. So, my espresso-fueled, Sunday prep-sessions have been cancelled moving forward.
It’s 6am on a Sunday, and I just got done with 1 hour of work. Am I crazy? Is this evidence of poor work-life balance? Should I be allowing my career to bleed into my everyday life in such ways? No (depends on who you ask), no and no. And the reason that I feel confident in saying that this hour of work isn’t evidence of not being able to keep up with the demands, or that I need to work on my efficiency and proficiency, is that I’m not actually playing catch-up from last week, but instead am getting ahead by PRE-CHARTING for this coming week.
Once emails, visit documentation and my EMR inbox are taken care of, then it’s time to begin proactively thinking about the week ahead. Sure, it would also be nice to just not work at all on the weekends, but the benefits of doing PRE-CHARTING and other preparations greatly outweigh the consequences of not doing so. Plus, I get to sit quietly, before the world around me gets going, sipping a delicious espresso, so the experience itself is generally positive.
I understand that even getting myself to the point of being “caught up”, wherein I can think about being proactive, may put me in the minority of primary care providers. After all, I wouldn’t have called myself “Efficient Clinician” if I didn’t have reasons to do so, but big picture, one of my goals for this website is to assist other providers in getting to a place where they can take more control of their clinical lives, and one way to do that is with PRE-CHARTING.
As I said, I believe that the benefits of pre-charting and other preparations far outweigh the drawbacks. We should think about it as a time investment, and the dividends that it pays are plentiful. Let me lay those benefits out for you, as I see them:
1) DECREASED CHARTING DURING AND AFTER VISITS: In a recent check of the Epic Signal data (the EMR use tracking system), I am about two standard deviations below the average time spent on documentation per visit, as compared to my peers. Another way to put that, by investing 1 hour into PRE-CHARTING, I am saving hours of work that others are cramming into their clinical days, including time spent outside of the office catching up on their notes.
2) TAKING CONTROL: Sometimes our life as clinicians feels chaotic, and PRE-CHARTING gives me that sense of control over what’s to come in the week ahead. By having most of my documentation already done ahead of time, I feel that I have increased my capacity to deal with the inevitable busyness that the week will be throwing at me. But at least I don’t have to worry about this piece of the puzzle.
3) LESS LIKELY TO OVERLOOK SOMETHING: By doing a brief overview of the chart, including diagnoses, medications, previous labs/imaging, I already have a nice patient synopsis from which to work from, come the day of our visit. I often pick up on a visit with a specialist, imaging from a recent ED visit, or other things that I might overlook in the demands of the moment. I also find that I get more out of our provider-nurse morning huddles, as I’ve already identified the expected needs of the patients on my schedule.
4) THOROUGH DOCUMENTATION: When I see that Mr. Johnson is coming in for right elbow pain, I load the diagnosis and pre-populate the visit note with my “Elbow exam” template, which already contains exam components for GENERAL/SKIN/MSK/NEURO/PERIPHERAL VASCULAR. A quick edit of those during or after the visit, along with already having loaded my review of the x-ray results from 2017, and I’ve built a 99214 visit by spending approximately 5 or less minutes on the documentation. I just fill in an HPI, edit the physical exam, write the medical decision making (aka Plan) and sign it off. I’m not sure that in the moment, should I be doing all of this real-time, that I would feel the ability to be as thorough.
4) MORE FACE-TO-FACE TIME: By not having the looming task of doing a full office-note after the visit, I spend more face-to-face time with my patients. I get to engage more with them, laugh more, ask about other concerns outside of their chief complaint(s), and I absolutely get to look them in the eye, as opposed to being a slave to the computer screen. It just feels like better patient care, and I know I’m on the right track when my patient, just the other day, said: “You always seem like you have all the time in the world with me.”
So, what I’ve found is that this 1 hour of preparation, along with other efficiency strategies that I have in place, have allowed me to improve my patient satisfaction scores, decrease my workload outside of clinical time, allot for more meaningful patient visits, better billing via thorough documentation (think meeting RVU goals) and have provided me with a sense of control over my work life. All of these positive benefits from such a small investment of time: I cannot recommend enough that you consider this for yourself, if not doing already. If you’re not sure how to get to that point where you are caught up and can begin to think ahead, stay tuned for more posts about efficiency and proficiency strategies to get you there.
FOOTNOTE: HippoEd did a nice segment on PRE-CHARTING, with link here.
DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.
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