Doing documentation efficiently safes time and nerves.
As doctors, we need to write a lot.

And the process of documenting anything we do can take an awful lot of time.

A standard pitfall

As young doctors try to cope with the multitude of information coming their way, the most frequently used method is to write notes into a small notebook, filling up page by page. They hope that they will transfer the information later to the “real” patient-IT-system.

There are specific risks associated with this approach:

• missing patient identifiers, resulting in mixing up patients
• extensive lists without organisation, prioritizing urgent above important
• risk of losing the notes containing patient-identifiers
• don’t take first notes and write later

I would like strongly warn you, as taking scribbled notes first with the aim to write them down nicely later. The effect of this is, that you will do double work!
In the hospital environment, you don’t have the time to do double work!

Doing documentation efficiently safes time and nerves.

The typical process of processing information

The typical process involves either writing with pen on paper notes. This is quick and easy, but the information is then only available at one place at one time. So often in healthcare environments, this is insufficient, and the information would need to be transferred to an electronic system, that allows non-localized updating and non-localized consuming of the information.

Doing documentation efficiently safes time and nerves.

How to get the information into IT?

As the majority of doctors are not very keen on typing on and on, the routine way of entering information into IT systems is frequently via dictating. In the NHS, we still rely on the professional typist, to perform the final translation. And this slows the process down, with delay on typing.

As a “work-around” we increasingly use AI supported voice-to text appliances. And they work, but we still need to proofread the written text, as the AI-supported voice to text translation still might be flawed.

Doing documentation efficiently safes time and nerves.

What kind of information do we see?

Although there is a lot of information floating around in hospitals, but they actually follow specific patterns.

1. specific patient:
   • assure that patient identifier is included first
   • either identifying number
   • name
   • date of birth
2. specific contact:
   • include contact details
   • telephone number
   • name
   • assure via read-back that your notes are correct
3. specific location: where are they?
   • in the hospital
   • in the community
   • at home
4. specific action required: assess urgency
   • urgent – life-threatening, action now
   • urgent – major threat, action within the hour
   • routine – major challenge, action within the next couple of hours
   • routine – to be dealt with at the same day
   • routine – just as additional information to take notice

The notes we take should reflect this system because, when we discuss the case with the next in the line of communication, they will need all this information to come to an informed decision.

Are there alternatives?

In my experience, one approach works best: the use of standardized text blocks.

Most of the electronic hospital systems do allow for the construction of individualized text-blocks.

Even if you are forced to use paper-based first notes for taking patient-information, you could design your own specific note-paper, so that in the heat of the moment, you don’t forget to ask all the important questions.

What do you need to create text-blocks for?

Anything that you write down more than 3 times a day, really should be transformed into a text-block.

Also, anything that you write down more than 3 times a week, could be transformed into a text-block.

Make documentation as efficient as possible.

These text-blocks can be formed into the following concepts:

• electric fill-in-forms for routine tasks:
  • taking telephone notes: see the questions above
  • registering patient’s background: previous medical history, allergies, …
  • listing the tasks to be managed for a patient: whom to approach, what specific task
  • ranking the tasks for the day: indicate for all demands their medical urgency
  • blank letter templates for admissions/ assessment/ discharge/ communications/ multi-departmental-discussions
• electric text-blocks for standard phrases
  • typical medical history
  • typical examination outcome
  • frequent atypical outcomes
  • typical treatment plan
  • frequent variation to typical treatment plan
  • greetings

In a nutshell

Whenever you need to take notes, aim to do this immediately in the final system and in the final form, to avoid double work.

Doing documentation efficiently safes time and nerves.

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