Unveiling the Hidden Curriculum of Ambulatory Medicine – Part 2: Efficiency

One of the best parts about the ambulatory care environment is the number of new consults that you can see in a day.  On an inpatient service, for every new patient you see there is time spent entering in admission orders, physically walking throughout the hospital trying to find rooms and patients who are constantly being pulled away for testing.  When I am on the inpatient service it is rare that I don’t hit my 10,000 step target, unless I am curled up in my bed post call.

In ambulatory care, patients come to YOU!  In a typical clinic day, you may be scheduled to see 1 new patient every hour, or two follow ups every hour.  That can end up being 7-8 new consults per day, or over 10 follow up appointments.  Think of the variety of cases you will see over your 4 week rotation.

Clock

With so many new consults, how can you stay on top of everything to make sure you get out at a reasonable time?  Here are some tips I’ve learned:

  • Arrive early when you can – Try to arrive 15 minutes before your scheduled start time. Getting a head start with chart reviews or even starting the first patient early can help you be organized and start the day off on the right foot. If you arrive when the clinic is scheduled to start and take 15 minutes to log into the computer and review the first patients, you will be late before you’ve even started your day. That time will be hard to make up unless a patient cancels
  • Chart as you go – It’s far faster to document in the moment. Consider opening up the chart on the computer in the room and typing quick notes (let the patient know that you will be doing this and don’t forget to still engage with the patient). Even if you take bullet points and make them into more cohesive thoughts, it will be easier to string together. When you’re done, and you’re waiting to review with staff, don’t just sit there, use that time to edit your note and complete as much as you can. If you find that typing is not fast enough there are phone dictation software programs you can download like Dragon Dictation.
  • Pre-chart your pertinent positives and negatives.  This is more for junior learners who may have a hard time remembering the complete review of systems.  This will help your memory and when you go to chart later you can condense these into one or two sentences.
  • Find templates that work – This is an EPIC specific tip!  Find a template that auto-completes prescription medications, lab values and the past medical history based on inputted data into the history section. This way you only need to enter something once and it will re-load at every visit.  You can also copy previous note, removing the HPI and impression and plan section or you can ask your staff if there is a division specific template.

Finally, don’t forget to spell check and read your note for clarity before you sign off.  Our staff note that most resident and med student notes are not adequately spell checked.  If you do this, you will look like a star!

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