How to achieve Effective Documentation? Different Ways
The patient encounter is the core of clinical physician practices. That’s why we went to medical school from the very beginning. The excitement and passion for seeing sick patients and helping them on the path of healing is an ambition. One skill set is to be a good clinician, and another is to ensure an efficient workflow. I want to highlight some tips for documentation.
Documentation
Different Approaches
Different physicians can have many different approaches to documentation. Here are some:
- Sit in front of the computer in the patient’s room and look at the screen while talking to the patient. This type of physician is efficient, but many patients won’t be pleased. The satisfaction scores may need improvement, too. Continuous eye contact is critical.
- Talk to the patient throughout the visit and document afterward via typing or dictation. The patients here are frequently happier, but the physicians are usually behind with their documentation and sometimes postpone the notes till the end of the day on busy days when they’re already behind. They will reason that patient care is more important than documentation.
- I saw a physician dictating in the room in front of their patients. Although efficient, I see it as needing to be more professional and interfering with the basics of good communication.
Touch Typing
If I don’t have all the details written right away, I’ll forget the details, which can be a big problem. I also like to have good communication with the patients. That’s why I love touch typing. I’ll talk to the patients and maintain eye contact while my hands are typing the notes. Sometimes, I need to look at my screen for a few seconds, like when placing orders or renewing medications. I’ll mention it, and I won’t be conversing then. I make my best effort to maintain continuous eye contact during active discussions.
I requested an adjustable cart and a laptop in each clinic to achieve that. Sitting comfortably or standing in the exam rooms and facing the patient during clinical encounters would be best. Many room designs need to have the computer set up that way. Commonly, you’ll have to rotate your neck 45 to 180 degrees to face the patient while typing on the pre-installed desktop; it’s unhealthy for your spine.
This is an example of an adjustable cart. Just ensure that what you will get is a good fit for your height and posture while standing and sitting. Your comfort is of utmost importance to avoid long-term subsequent musculoskeletal consequences.
