Going vertical: documentation at the bedside

HOW MANY TIMES do patients complain that their hospitalist seemed rushed and spent only a few minutes with them? It’s an almost universal lament, and it’s due to the fact that our workdays are so harried.

I chalk that up to two facts of life in hospital medicine. First, we’re prone to constant interruptions from staff, colleagues, and patients and their families. And two, we spend more time with our computers than face-to-face with our patients.

Having worked at many hospitals around the country, I’ve observed how hospitalists round with two goals in mind: finishing our documentation and finishing on time. I think we fall into three distinct types—although I suspect we have all used all of these techniques at one time or another.

■ The Phantom: Generally, this hospitalist is seldom seen. Her routine is to collect chart data after morning report, round on five or six consecutive patients, then sequester herself at a hidden computer station to complete her chart and order entries. Her documentation looks fine, but sometimes she finds it hard to keep information separate on five or six patients seen just a few minutes apart. She believes that multitasking is no problem.

Using the WOW allows me to spend more time at the bedside

■ The Schmoozer: This practitioner does not go into hiding. Quite the contrary; as the ultimate extrovert, he enjoys the social experience of mingling with his colleagues. The Schmoozer is typically found at the ward workstation or in cubicles that have several computers lined up. He usually spends about the same time seeing patients as the Phantom, but he has mastered the art of cut and paste, and daily notes look remarkably similar. He is well-liked by the medical staff and has a wealth of information on hospital gossip, national and local politics, and great restaurants and weekend getaways.

■ The Compulsivist: Her technique is to see one patient at a time. First, she checks data in the computer at the physicians’ workstation, and she may spend more time at the bedside than many colleagues. She also finds multitasking to be anathema— but as the day goes on, she finds less and less bedside time for patients because she is trying to finish on schedule.

Nurses and other staff members love this hospitalist because she is readily available, seated at the physicians’ workstation. Unlike the Schmoozer, the Compulsivist does not initiate social conversations. But she is much too nice to cut such discussions short, and burnout is just around the corner.

So what do all three rounding types have in common? They all spend most of the day sitting and staring at a computer screen.

An initial skeptic
As for where I fit on this spectrum, I tend to be a Compulsivist, although I find that the Phantom model works best with high patient loads. In any event, I was surprised when my hospital administration asked me to test out the use of a “WOW,” a workstation on wheels with a computer, one that I would roll into patient rooms while I round.

Nurses use these all the time as do many hospitalists, but not, I think, to their full potential. I was certainly skeptical that a WOW would help me do a better job, but I now really appreciate the advantages—to me and to patients—from bringing my documentation with me to the bedside.

Here is how it works: I knock on the patient’s door, then roll in. After exchanging a few pleasantries, I open up the patient’s chart on the WOW and review previous information, problems and/or results, usually sharing important information with the patient.

After performing a pertinent physical exam, it’s time to interact with the computer—but I don’t exclude the patient. I enter orders and complete the progress note, history and physical, or discharge summary, either by typed template or dictation.

I prefer dictation using a microphone attached to the WOW and voice recognition software (such as Dragon Medical Practice). The patient now has an opportunity to hear precisely what is going into the chart, and while some of that is medical jargon, most patients get the gist of what I am recording. Even more importantly, they see me in action working on their case— and sometimes even correct me if I misunderstood some of their reported symptoms.

Before I leave, I always ask two questions: “Do you need anything?” and “Do you have any questions?” If patients have problems or concerns, especially of an emotional nature, I stop, sit down—an exception to staying vertical—make eye contact and try to allay their anxiety. When I need to record psychiatric observations, I do my dictation outside the patient’s room and find a quiet niche somewhere down the hall to finish.

Working more efficiently
I know that experts, in an effort to improve patient experience, recommend that hospitalists take a seat by the bedside, something I’m not doing when standing at the WOW.

But using the WOW allows me to spend more time at the bedside. Plus, hearing me dictate reinforces the discussions I’m having with patients—all of which, I believe, helps improve patient experience and care.

While patients like the fact that I spend more time in their room, I find working with the WOW to be much more efficient. I’m able to finish my orders and notes without being pulled into chitchat or having staff members lined up next to me at a workstation, waiting to interrupt whenever I pause during dictation.

Then there’s this: Psychologically and physically, standing beats sitting hands-down. Studies, including one published in July 2016 in the Institute of Industrial and Systems Engineering Transactions on Occupational Ergonomics and Human Factors, found that normally sedentary workers in a call center were about 45% more efficient when working instead at a standing desk.

So far, my colleagues haven’t requested their own WOW. But I’m sold, and I will continue to use mine. While I continue being a bit of a Compulsivist, the rolling workstation allows me to express my OCD tendencies while still getting me home on time.

Stephen L. Green, MD, is a locum hospitalist who maintains a telemedicine infectious disease consulting practice. He previously practiced for more than 30 years as a primary care internist and infectious diseases specialist. Dr. Green can be reached at sgreen5528@aol.com.

Published in the November 2019 issue of Today’s Hospitalist