Most doctors wish they could spend less time on paperwork and charting. One of the best ways to save documentation time is to write your clinical notes faster.
“But I already write my clinical notes very quickly!” you say. It’s true that you probably take notes quickly if you’ve made it this far in medicine. But could you complete EHR documentation 10% faster? How about 20%?
Small documentation efficiency gains pay off quickly for clinicians, who often spend a quarter of their workday in the EHR. Simple math shows that completing clinical notes even 10% faster would eliminate a week of EHR time each year.
Whether you’re a veteran practitioner, an efficiency aficionado, or a new medical student, these tips will help you complete medical notes more quickly.
Nine tips for writing medical notes faster
This article lists several ways to write medical notes faster. Rather than dive deep into each tip, we’ve linked to other articles or resources that provide more details about each strategy.
As you read, ask yourself, “Which of these tips might help me write faster and better clinical notes?” Change is hard, so pick just one tip and try it for the next month.
1. Standardize your notes format
Whether you use a simple SOAP note or fully-customized EHR templates, standardize the format of your notes. You’ll write clinical notes faster using a consistent format you know well.
2. Be concise
This tip may seem obvious, but it’s easy to get in the habit of saying more than necessary. Kevin MD has some helpful examples of putting this tip into action by using abbreviations, removing pronouns, and thinking in bullet points instead of paragraphs.
3. Be OK with typos
Perfectionists will hate this tip, but don’t bother editing typos unless they impact the clarity of your note. The EHR is a communication tool, not an essay, so you don’t need to capitalize every letter or use punctuation.
4. Dictate instead of typing
Even if you’re a professional typist, you speak faster than you type. Consider using a speech-to-text medical dictation app to dictate clinical notes and ditch typing entirely.
5. Document in real-time
With the proper documentation workflow, taking notes during patient visits can improve the patient experience by allowing you to reiterate and summarize the plan. Learn how other providers use real-time dictation to implement this simple, time-saving tip.
6. Implement team documentation
Do non-physician members of your team assist with visit notes, orders, and other follow-up tasks? A well-executed team documentation workflow can reduce your documentation time and elevate the clinical staff’s role.
7. Use an AI scribe
Generative AI has made it possible to automate clinical documentation nearly completely. Consider implementing a smartphone-based AI medical scribe that listens to your conversation with patients and automatically drafts your notes.
8. Avoid distractions and interruptions
A common mistake doctors make is to try to squeeze clinical documentation in between everything else. Unless you intentionally document during visits, set aside distraction-free time to complete clinical notes and be fully present. You’ll complete clinical notes faster if you turn off notifications, close the inbox, and find a quiet space.
9. Seek feedback and training
Depending on your workplace culture, directly requesting feedback may be unusual. However, your staff and colleagues have a wealth of experience and can provide valuable outside perspectives.
Try asking your closest clinical colleagues this simple question: “What is one thing you think I could do to make my clinical documentation process more efficient?” Be open to their input, and seek training if you need help honing your skills or learning new technology.