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Effective and Efficient LCR Charting Naomi Schoenfeld, FNP Lead Clinician Family Health Center. Goals. Improve NP job satisfaction and decrease burnout risk by improving charting efficiencies Make the best of a clunky system in its dying days. Objectives. By the end of this presentation:
Improve NP job satisfaction and decrease burnout risk by improving charting efficiencies
Make the best of a clunky system in its dying days...
By the end of this presentation:
Participants will be able to name at least one time-saving strategy for LCR charting
Participants will improve their ability to enlist the computer as an ally and teaching tool in clinic
Take advantage of what it's good for:
Keeping track of medical problems like
Plavix that needs to be stopped after 1 yr
Copy your old notes
Using computer to share information with patient
Graph of lab results
Pull up pictures or videos on internet
Let the patient in on the EMR/LCR
Tell them what you're doing “I'm going to start typing so I can keep track of all the details you're telling me.”
Let them see you completing e-referrals
Let them see you putting meds in and faxing them
Show them Lab results
Talk to the patient before you interact with the computer
Let the patient answer an entire open ended question before logging on to the computer.
Pause for eye contact
Use reflective listening skills
Value the computer
Resist the urge to criticize the LCR
Emphasize the positive
Studies show that when patients hear providers complain about the computer, the primary effect is that they lose confidence in the provider
Especially if you are going to spend more than 20 seconds in the screen, let the patient know what you're doing.
Patients' number one concern about EMRs is security
Let them know that you are “securing” or “locking” their record
Prevent HIPPA violations
What are the goals of writing notes?
Quality patient care, communication
It's ok to have typos, misspell word occasionally, and to use commonly used abbr.
As soon as you log on, before you look at labs or what-not, open your note so you can type whatever comes up as it happens
This let's you go toggle from screen to screen without having to save/close/re-open note.
Alt Tab Caution:
Don't forget you have an open note! If you accidentally open another one you will lose what you have written
Avoid losing your note. If you will not be entering any text for more than 15-20 min, hold note!
If a note disappears, check Notes In-box.
Type while talking, doesn't have to be complete sentences
Take breaks if you need to turn and listen, just type in a few words to remind yourself to fill it in later
If you leave gaps try typing ++++++ to remind yourself to fill it in later
MINIMAL IS USUALLY BETTER FROM BOTH A PRACTICAL AND LEGAL PERSPECTIVE
“No red flags” will hold up in court better than listing an incomplete list of negative ROS.
Example: pt c/o LBP x 5 days w/o injury. No help with ibu otc. No red flags.
Usually can finish this part during interview
Can either copy it from last visit or problem list OR don't include in every note
Eg “see problem list LCR”
Do initially, update periodically, but do not need to include in each note
Eg “see note dated 4/18/13 for complete SH/FH
Just let people look at the LCR
Eg “see medlist LCR”
Vital signs: if MEAs enter in LCR and they are WNL, can just refer to this
See vs lcr
Best to include abnormal vs in your note
General PE: If you have a standard practice you can keep it minimal.
Consider just charting pertinent +'s and -'s.
Don't list them!
Consider: “labs reviewed in LCR”
Maybe write 1-2 really relevant values
Studies: just refer to them, don't copy them in
Only address active problems/chronic problems
For old/inactive, can leave in PMH or say “not addressed today”
Some find it helpful to include a note at the bottom to remind themselves what to do at next visit:
Eg: NV: TDAP, FLP, A1C, BMP, PAP, BP CHECK
Can use note category “Records Outside Facility” Can jot down a few pertinent notes from outside records...
Finish subjective during interview
Do e-referrals with patient
Order meds/refills with patient watching on to reinforce med review
Try using teach-back time to complete PE, A/P
Just when you're an expert....
You'll move to eCW!