Paperwork Bogging Down Family Physicians

[fam_gunner]

It is commonly stated that family medicine docs can be bogged down with administrative duties and paperwork. I was curious if any FP's could speak to the validity of this. Im wondering what these administrative duties/paperwork are specifically. A few that i can think of:
- referrals: what is actually involved? Take me through it.
- Notes from an appointment. Px comes in for a physical, what notes are needed?
- Filling out forms: I understand that you can charge for a significant portion of these which seems to lessen their burden

[gangliocytoma]

One of my former preceptors said that every hour of patient care generates an hour of paperwork. You don't appreciate it as much when you're in medical school because you're insulated from it but as a resident when the responsibility falls to you it starts to add up. As a FM resident I'd spend roughly 2 hrs after clinic finishing up notes, writing referrals, cleaning up inbox. Inbox becomes something that takes a large amount of your time and scales up proportionally based on the size of practice you have. I've had many preceptors that spend many evenings of their week working on the inbox and following up with patients so consider this when deciding how large a practice you hope to have.

1- referrals; these can be as short and poorly written as you'd like them to be. EMRs these days allow you to copy and paste pmhx and meds. If you write a poor and vague note expect your patient to be triaged pretty low unless you specifically state you're worried about something. The length and detail of a referral probably depends on what you want from a consultant - i.e.  simple question and take over care vs complex and somewhat undifferentiated patient that you aren't sure how to manage. The consultant should do a thorough assessment nonetheless. On off-service rotations I've seen FPs send patients to derm with a note saying literally "Plz assess skin lesion" which turned out to be a skin tag vs others with 3 page extensive notes summarizing multiple previous visits relating to the problem along with a detailed physical exam and everything they've tried. I think consultants prefer brevity for the most part but sometimes too brief becomes unhelpful for everyone. Econsults tend to take more time and thoroughness bc the consultant will not see the patient in person, so to make them useful you would put more details in order to get a more useful answer.

2- notes; in practice you are responsible for your own notes. No one checks them once you are staff so you can be as thorough or short as you want. But, if for some reason you get sued (which most physicians do at least once in their career) or get a CPSO complaint lodged against you, your notes will be your only friend or your worst enemy. These can be streamlined by making templates that you fill or by dictating using software which is faster than typing/hand writing. Obviously you should document pertinent positives/negatives, physical exam findings like murmurs, absence of pulses, neuro findings etc. Another reason to have good notes is if you take time and need to hire a locum. It would be a good idea for them to know what you've done with your patient. I guess under notes you could probably include updating your EMR to make sure the pmhx, medications, preventions are all up to date. This tends to happen as inbox items come in.

3- yes forms are a pain in the ass. I found I was inundated with them. Some days it felt like all my patients were coming in just to complete forms. Sure you can charge for them but if the patient can't afford them or won't pay then what? you risk them never coming back to see you again and use walk-in clinics and eat into your capitation billings. It will very much depend on the type of patient population you have. The other question is how do you feel about charging a single mother who is off work long-term for mental health reasons coming in to get LTD insurance forms filled? Some would say it shouldn't matter, others will let it slide. It depends on where you stand ethically and morally. You could still technically bill OHIP for the visit as you'd be doing an assessment any ways and then fill the form pro-bono. Some forms like WSIB and ODSP allow you to bill directly for them avoiding having to charge the patient. Depending on how well you know your patients/how simple the issue is, these forms could be a simple 5 min task vs an extensive chart review. I personally found private insurance forms the worst because of the detail some of them required.

hope that helps

[The Ace of Spades]

11 hours ago, gangliocytoma said:

I think consultants prefer brevity for the most part but sometimes too brief becomes unhelpful for everyone.

Yes, I gouge my eyes out when I receive a 30-page referral package. Just send a quick paragraph with pertinent details/history and relevant labs. I loathe copy + pasted EMR crap or piles of lab work that I have to sift through to find what you want me to find.

[gogogo]

Just started FM residency. There is a lot of paperwork. I spend maybe 2h over-time each day to complete it. Experienced physicians (who also bill well) tell me that they spend anywhere between 0-1h at the end of the day to complete paperwork, so I think you get more efficient as time goes on.

 

Paperwork includes: evaluating patient labs/imaging reports, reading specialist’s consult or follow-up note, script renewals, hospital discharge notes, and forms for patients (insurance forms, disability, etc.). It’s overwhelming at first, but if you’re organized and write clear notes for your patients, it’s easy to integrate incoming labs, reports, consults, etc. into your existing plan. If you write crappy brief notes, every time you receive something new about a patient ends up requiring digging to figure out why you ordered that bloodwork, etc. in the first place.

[medisforme]

I am a Fam Doc in BC and consider myself extremely efficient and someone who probably overcharts/documents slightly.  I see approximately 15-16 patients per half day clinic.

• 45min each morning prior to clinic reviewing charts for the day, pre-ordering imaging, lab test and getting templates set up to help shorten actual appointments
• Any time I have even 1 free min during the day, i am going to my task box to review labs, consults etc...  This means there is essentially no down time between 0900-1645 or so daily
• 20min of lunch hour spent catching up on charting, reviewing labs
• 20-30min at end of the day spend catching up on charting and reviewing labs
• 20-30min every evening at home once kids are in bed spent either catching up on documentation or else reviewing labs etc...
• spend approximately 1-2hr a week doing forms etc... all of which I charge for unless I know patient has extreme financial stress

It took a lot of EMR review, set up time and practice to get to the above.  When I first started out, I was spending 1-2 hrs a night charting/reviewing labs which I hear is the norm for a lot of family doctors.  The unpaid paperwork and review is a major reason why many new grads do not go into longitudinal family medicine.  None of the above applies to hospitalist or niche areas of family medicine.