How To Write Notes Efficiently

In all specialties, but especially in medical specialties, efficient (but not perfect) documentation will have an impact on your well-being and your overall success as a resident. If you are identified early in residency as having “difficulty completing notes on time,” it is challenging to later shake this reputation and can even lead to being let go from your program (though not the only reason, this shortcoming allegedly contributed to my co-resident’s dismissal). 

Less Time Writing Notes, More Time For Yourself

Really a cornerstone of the nebulous “time management is important” advice, the less time you spend writing notes, the more time you will have to read/study/meditate/sleep/eat/exercise. Your documentation will directly impact billing, whether you are expected to bill directly or your attending uses your documentation to bill. Your documentation needs to be good but not perfect–do not spend the time it would take to write perfect notes. In my program, residents preliminarily billed for outpatient encounters and attendings billed for inpatient encounters. 

Gaining Efficiency With EMRs

Your program may require you to use numerous EMRs/EHRs (electronic medical records/electronic health records) like mine did (2 outpatient and 4 inpatient). Additionally, the EMR(s) you are required to use may be completely new to you. However, you must get up to speed quickly. My program had resident EMR “superusers,” who were paid a small stipend to help other residents with EMR optimization. If your program does not have “superusers” or there are none in your department, senior residents/other residents in your specialty are likely your best resources. 

What I saw during residency as an annoying weakness of my program, I later realized could be a benefit. Exposure to a variety of EMRs helped prepare me to be an attending, because I knew that I could get up to speed quickly, no matter the EMR. Additionally, I could confidently tell prospective employers that I was comfortable with their EMR, because I used it in residency. 

Dictation Software For Notes

Similarly, I was one of the many residents who told myself: “I type quickly, therefore, I am not going to use voice-to-text technology.” I finally tried Dragon voice-to-text technology midway through my second year and have never looked back. I immediately noticed efficiency improvement and have continued to use its many features as an attending.

Key Takeaways For Resident Time Management

  • Exposure to a variety of EMRs is a strength, not a weakness, and a potential selling point when applying for jobs.
  • Ask “superusers” or other residents for tips on how to efficiently complete your notes.
  • Embrace Technology – it is unlikely that you can type faster than you can speak.


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