1. Effective and Efficient LCR Charting Naomi Schoenfeld, FNP Lead Clinician Family Health Center

2. Goals Improve NP job satisfaction and decrease burnout risk by improving charting efficiencies Make the best of a clunky system in its dying days...

3. Objectives ● 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

4. General EMR Tips ● Take advantage of what it's good for: – Tracking HCM – Keeping track of medical problems like ● Pulmonary nodules ● 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

5. L.E.V.E.L. ● 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

6. L.E.V.E.L. ● Empathetic Cues – 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

7. L.E.V.E.L. ● 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 ● Explain – Especially if you are going to spend more than 20 seconds in the screen, let the patient know what you're doing.

8. L.E.V.E.L. ● Log out – Patients' number one concern about EMRs is security – Let them know that you are “securing” or “locking” their record – Prevent HIPPA violations

9. Dr. Costanza vs. Exemplary Computer-User, NP ● youtube link... ● http://www.youtube.com/watch?v=LZAqeJtpzEY http://www.youtube.com/watch?v=LZAqeJtpzEY

10. Tips for Writing Efficient Notes ● General Reminders – What are the goals of writing notes? ● Quality patient care, communication ● Justify billing ● Legal document – 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

11. General Computer Tips 'n Tricks ● ALT TAB – 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.

12. Content Tips ● Subjective/HPI – 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

13. Content Tips ● Subjective/HPI cont'd – 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 ● PMH/PSH: – Can either copy it from last visit or problem list OR don't include in every note ● Eg “see problem list LCR”

14. Content Tips ● SH/FH: – Do initially, update periodically, but do not need to include in each note – Eg “see note dated 4/18/13 for complete SH/FH ● Medications – Just let people look at the LCR – Eg “see medlist LCR”

15. Content Tips ● Physical Exam – 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.

16. Content Tips ● Lab results – 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 ● Assessment /Plan – Only address active problems/chronic problems – For old/inactive, can leave in PMH or say “not addressed today” –

17. Content Tips ● A/P Cont'd.. – 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 ● Outside Records – Can use note category “Records Outside Facility” Can jot down a few pertinent notes from outside records...

18. Maximize charting during visit ● 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

19. Practice! ● Just when you're an expert.... ● You'll move to eCW!