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: – 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

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

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

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

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.

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

Dr. Costanza vs. Exemplary Computer-User, NP ● youtube link... ●

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

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 min, hold note! ● If a note disappears, check Notes In-box.

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

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”

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”

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.

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” –

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...

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

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