Taking clinic notes on laptop vs. paper

[SteinUmStein]

Curious what everyone's experience and perspective is on taking notes during primarily medication-management, general adult psychiatry appointments. I haven't tried this myself, and have stuck to tried-and-true pen and paper, though have had colleagues who seem to be having good success in running clinic in the same way as usual with the only difference being typing on a laptop in their lap or on a small desk instead of writing. So far I've heard that it doesn't seem to interfere in the interview, particularly if able to type while maintaining eye contact, and assuming patient gives permission for typing during session. Just curious as my initial reaction was negative, but I could see this making 20-30 minute follow-up appointments immensely more productive and enjoyable (could use entire session instead of ending early for notes, could take more accurate notes instead of re-writing and remembering later, could reference chart and med history quickly in session). Obviously this wouldn't be used for therapy or therapy-like sessions. If I were to try this, I would give the patient the chance to "opt out" prior to starting typing as some patients might be less comfortable. Anyone have bad experiences or have any horror stories to share before I give it a try?

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[TexasPhysician]

I find typing during interviews to be immensely distracting to patients, and it increases documentation time. Paper templates are faster, easier, and better received during appointments in my opinion. I use an emr for scheduling and eRx only.

While I do have a cash practice, I've worked at insurance practices before. Patients using insurance are generally just happy to get in, so emr would not generally lose patients. It will slow you down in clinic though.

 

[Shikima]

I find typing during interviews to be immensely distracting to patients, and it increases documentation time. Paper templates are faster, easier, and better received during appointments in my opinion. I use an emr for scheduling and eRx only.

While I do have a cash practice, I've worked at insurance practices before. Patients using insurance are generally just happy to get in, so emr would not generally lose patients. It will slow you down in clinic though.

Plus being cash has it advantage because you aren't subject to the stupid governmental rules of managed care.

 

[SteinUmStein]

That's interesting and helpful, thanks for the input. I'm mostly referring to systems that require an EMR like Epic or Cerner or others, where paper notes are not an option. I could see typing being a distraction for patients. I've sat with internists/family docs both as a medical student and as a patient, and they frequently type, which has never bothered me - but it's also not a psychiatric visit and I'm a younger individual who understands computers are a central part of healthcare now. I can see both sides - I've spoken to psychiatrists, residents, and psych NPs who frequently use a keyboard (particularly laptop which generally makes little noise typing) who don't feel it detracts for general med visits. Maybe more appropriate for well-established, routine RV's rather than struggling pt's or new evals? Certainly never appropriate for therapy or combined meds/therapy. Always fine to jot notes on paper I suppose, I just anticipate employment (at least for the next few years) in systems requiring EMR notes, which leads to an extra set of steps and time to transfer scribbled visit notes to typed notes, and that tends to come out of either personal time or out of visit time (i.e. 30 min apt, 20 min with patient and 5-10 min to type frantically).

Any thoughts from someone who has tried typing during visits in the past? Anyone struggle with this same issue or do you guys have it down?

 

[hamstergang]

I'm moving towards typing as it speeds me up and I can type well enough while listening and making eye contact. My only issue is the position of the computer, and some offices makes that tougher for me.

I will stop typing if the patient starts talking about deeper, more depressive things as it seems more respectful not to type while they're saying that.

 

[SteinUmStein]

Thanks for the input. If I tried this, I was thinking maybe a small laptop with a quiet/soft keyboard (difficult to hear key press even at short distance, not a loud regular keyboard) on lap or on a small rolling desk (like one with a flat arm section you can move or rotate) - assuming the desk setup isn't workable to have a small desk in front or adjacent for comfortable face-to-face interaction. I would certainly never sacrifice rapport or the relationship for this small convenience - I think I'd actually ask permission from each patient before moving that direction as I would prefer spending more time on pen/paper and typing later than harming the treatment relationship or appearing disrespectful of patients or appearing "rushed" or distracted. What prompted me to think more about this was noticing in the past few days how much I look down as I write/find my place/label new sections of visits (esp new evals), and noticing that it seems to break eye contact more than might happen if I could free-type into a blank note as I go.

Just curious what experiences are out there as I think typing notes for med RVs is probably more common than some might think, especially in health systems with required EMRs - it's just a huge difference in time that adds up every visit if you can't use your written notes as your documentation.

 

[F0nzie]

Dat clickity clack


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[SteinUmStein]

Dat clickity clack


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Well.... what about with a reeeeeeally quiet keyboard/laptop?? I don't know, maybe I should skip it and just try to type shorter notes after visits, esp well-established follow-ups. In general I'm trying to write down less during the visit, as the psychosocial info and updates du jour can and should be summarized in 1-2 sentences for most visits, IMO, unless specifically relevant to symptoms/treatment. A big change in workflow and habits from my residency inpatient days, where we were encouraged to write psychosocial, diagnostic, and developmental novels that no one has read to this day.

 

[clausewitz2]

So I sometimes participate in a dialogue our community psych folks organize between residents and SMI consumers and a really common theme that emerges is that they really hate when their psychiatrist is typing when they are talking. Eye contact seems not to matter, they feel like you are not really paying attention.

There is some obvious selection bias here, but a small smattering of patient-centric anecdata. Even if you are making eye contact and feel like you are capturing things verbatim, they may not feel like you're very present.

 

[SteinUmStein]

Interesting - I can understand that and I'm glad those dialogues exist, what a great opportunity. Like when someone is texting on their phone, even briefly, makes it seem like the whole conversation they are elsewhere. And I could see it being aggravating or even insulting to feel distanced or ignored by the one physician who really needs to hear, understand, and connect with you (contrasting what we hope to achieve in our sessions with a stereotypical PCP's quick RVs, which frequently involve a doctor staring at a computer, typing frantically, and then fleeing the room). I will definitely keep that in mind, I'm glad I asked this forum. Seems like a small thing but could dramatically change day-to-day practice and the sense the patient gets in the room. Wish this kind of practical topic came up more in residency and/or med school, it's a big decision.

 

[Liquid8]

A very interesting discussion, although at the end of the day you have to find a system that works for you. Just last week a patient who I’d seen for a one-off assessment a year ago rebooked with me – during that time she’d seen another psychiatrist a couple of times who was cheaper and closer to her home, but the deal-breaker was that she couldn’t stand that she was always typing and not listening (or at least not appearing to).

When I started out in private, I did type during the interviews but there were some specific incidents which made me revert back to pen and paper. I also wasn't convinced that it saved me a lot of time either especially in regards with writing correspondence to referring doctors. Essentially the patients I see are rarely so straightforward that they give a history in a format that can just be copied/pasted to a letter without substantial editing, and I had found myself spending more time going over things. Switching to using dictation software helped significantly, but then I found it was easier to dictate from my paper notes than switching back and forth between electronic records. At present I have a manila folder for each patient, and usually type and print out my notes for the file after each session. I have found this helps jog my memory and makes it easier to refer back to things during future consults without being stuck in a screen and breaking engagement.

 

[SteinUmStein]

I think there's real risk that's easy to ignore/justify in possible behaviors like "briefly glancing" at the screen to quickly edit, delete, or add to typed documentation, or "glancing" at a past note or med doses in session - pretty soon your computer is part of the transference-countertransference equation and it's an unwelcome presence in the room. Not to mention the whole dynamic (conscious and/or unconscious) that the more documentation you can "get done" in session, the less of your own time will be spent out of session, etc. I'm quickly realizing this is more than just a little flow/documentation or time-saving decision and more of a "how do you want to practice psychiatry, how do you want to be seen by patients" decision. Thank you everyone.

 

[Armadillos]

Is it common for folks to take a lot of almost verbatim notes about the dialogue during a followup? Seems like a several sentence summary plus some positives and negatives is plenty?? Now if someone is good enough to be typing the plan and MSE while still engaged in the interview, then more power to you.

Intakes I can see the temptation to type during the visit, especially to get dates/med does etc.

 

[OldPsychDoc]

I find that when I turn to the computer to check meds and order refills, it is a useful signal to the patient that "This visit is ending now."

 

[TexasPhysician]

Is it common for folks to take a lot of almost verbatim notes about the dialogue during a followup? Seems like a several sentence summary plus some positives and negatives is plenty?? Now if someone is good enough to be typing the plan and MSE while still engaged in the interview, then more power to you.

Intakes I can see the temptation to type during the visit, especially to get dates/med does etc.

With paper, I complete the entire note with the patient. With a computer in the past, I needed to complete non-history portions after.

 

[HarryMTieboutMD]

Maybe it's a generational thing but I MUCH prefer EMRs to paper notes, and I prefer typing to dictating. I would rather not have to read through my illegible handwriting from a previous note (for some patients my notes can be pretty detailed if I need to remind myself of my line of thinking), and the LESS paper I have to touch, the better.
I hardly spend any time outside of clinic working on notes; I can write a pretty detailed note with detailed MSE in about 5 minutes (irrespective of the EMR, one of our clinics has the worst, most user-unfriendly EMR EVER).

People who complain about EMRs are usually older, baby boomer (WORST generation ever) doctors who are outdated in thinking (and often times practice) who are resistant to change in any form at all (though I do agree that in a cash only practice not having to comply with the BS government mandated components of a note would be nice... but I'd still do everything in an EMR- but I would never do cash only- rich patients are the worst!)

EMRs are also excellent data mines, and I have/am publishing several interesting paper using years worth of data that our hospital has just from the EMR.

 

[TexasPhysician]

I'm < 35 and prefer paper.

 

[jaymon]

I think it's just personal preference. I'm less than 35 as well, but hope I never have to use paper. That would actually be enough to influence me to not take a job. EMRs just seem so much better to me. I type my notes after the visit though. I feel like doing it during the appointment would be a distraction.

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[tr]

I used to do pen and paper and transfer to EMR afterwards, and I'm sure patients prefer that as I agree that watching someone type is distracting, but frankly I don't care. I work in an AMC, I'm stuck with the EMR we have, and transferring written notes into the computer is a time sink that I cannot afford.

My notes are pretty concise and I usually am able to finish them or nearly so while the patient is in the room. I probably spend a total of 5 min out of a 30 min or 1h visit typing. For the most part, I maintain eye contact with the patient while I type. I might need a little cleanup time to make the note comprehensible after the visit, like 1-2 min for a return and 5-15 min for an intake.

If I were in private practice and I cared more about the patient's impression of my note-taking procedures I might use preprinted paper forms, they seem like they could be really fast and nondistracting.

 

[TexasPhysician]

I don't think it is possible to be faster than a template pen/paper. Documentation can be under 1 min during the eval.

 

[FlowRate]

I don't think it is possible to be faster than a template pen/paper. Documentation can be under 1 min during the eval.

I think people are missing that you're using a template, which I assume means you're not handwriting a full note on a blank chart page, you're circling ROS, treatments, etc

 

[Bartelby]

I think there's real risk that's easy to ignore/justify in possible behaviors like "briefly glancing" at the screen to quickly edit, delete, or add to typed documentation, or "glancing" at a past note or med doses in session - pretty soon your computer is part of the transference-countertransference equation and it's an unwelcome presence in the room. Not to mention the whole dynamic (conscious and/or unconscious) that the more documentation you can "get done" in session, the less of your own time will be spent out of session, etc. I'm quickly realizing this is more than just a little flow/documentation or time-saving decision and more of a "how do you want to practice psychiatry, how do you want to be seen by patients" decision. Thank you everyone.

I think this is spot on. For intakes, I use a clipboard and jot shorthand notes for myself about details I might forget (exactly how many hours of sleep per night, PCP's name, particularly illustrative quotes, etc.). I then type a note. For followups that are known to me, I often don't take any notes during the session at all. I agree with HarryM, typing or dictating a note does not take long.

Circling notes by a template could be an okay way to go, as long as you are also documenting things like a risk assessment and demonstrating medical judgment with them. I think some kind of hybrid where some of your own thinking comes through would be useful. When I have received templated notes from many facilities (circling various descriptors, jot one illegible line about the patient) they have been pretty much complete trash.

 

[tr]

I also think a lot of psychiatrists in our system put way too much stuff in their notes. I see no purpose at all to documenting psychosocial details, and some potential for harm. Other doctors only read the a/p. The s/o is just billing fodder until some lawyer subpoenas it and uses it to make your patient look bad in their divorce case or whatever.

My S is 2-4 sentences that are relevant to the plan and include some ROS items for billing, most of the O is copied or autopopulated (the MSE just gets minor updates usually), A doesn't usually change much, and P is bullet points that are fast to update.

 

[grapefruit17]

It would be interesting to see some of the notes from the veterans on here as a reference for us newcomers. Maybe with all the patient info taken out but that would probably amount to a giant hassle editing it so it's not a violation.

I like the idea of using a template and writing notes. But I made my own two page template based upon my readings and how I'll organize the soap note.

 

[SteinUmStein]

Anyone have a basic, generic example of a level 3 or 4 medication RV f/u note? I think our health system tends to overdocument, myself included... thanks!

 

[Ceke2002]

As a patient it would be pretty close to a complete deal breaker for me.

 

[carlosc1dbz]

What is a good laptop to use in private practice. Any non Apple recommendations for documentation? I personally like Apple computers, they are just so expensive.

 

[Shikima]

What is a good laptop to use in private practice. Any non Apple recommendations for documentation? I personally like Apple computers, they are just so expensive.

And the hardware is cheap and underpowered.
Long live the PC master race!