Patients or paperwork, take two

The fine line on documenting is helped by dictating (paying a secretary to type it out)...however, there is a two day average delay in getting it down...

So you have to write everything on the chart, and THEN dictate--double duty. IN the past, I always summarized what was important, and dictated the chaff...

Another way to summarize is to list the problems, then summarize what you saw to emphasize why that diagnosis or problem was on the list.

Then we have the nursing type records: Three pages of checkmarks, originally for nursing diagnoses, but I've used them in ER's...again, the problem is that the vital stuff is lost in the checkmarks.

Maybe computerized records are the answer: You put the vital stuff in the main part, and the chaff/normal/unimportant (like a false eye in a stroke patient) in a pop up window. But again, that takes time...and maybe using Dragon or similar voice dictation programs will work faster than hiring a secretary (and now some secretaries are outsourced to other countries).

In the meanwhile, until we have computerized records, (coming next year) I will continue scribbling my summaries and not getting paid for my time due to lack of "documentation" of all the different systems needed for medicaid/insurance billling....

Dr. Casey, call your office.