You're probably no stranger to the struggles of charting as a therapist. Between client sessions, paperwork, and running your practice, it's easy for record-keeping to become a time-suck.
But what if we told you there are some simple tricks that can help make that dreaded charting time much more manageable?
In this article, we’ll share eight tips that have helped many therapists turn their frowns upside down when doing charting.
From leveraging smart phrases to leaving it to state-of-the-art AI, these will help you spend more time doing what you love: Helping out your patients.
We'll cover:
- How to streamline documentation with smart phrases
- Why you should try to complete notes during the session
- Get protected admin time for charting
- Automate your note-taking
- Team up for charting
- Let patients chip in
- Make templates your friend
- Set up charting checkpoints
- Get back your time by leaving psychiatric note transcription to Lindy
Let's dive in!
Tip #1: Use smart phrases to streamline documentation
- Turn typing into a game: Whip up smart phrases for those repeat offenders in your notes. "The patient reports" becomes a tap away instead of a tedious type-out.
- Have a cheat sheet of phrases: Stockpile your go-to's like "Increased anxiety levels" into a quick-click arsenal, making note-taking less of a chore.
- Customize for the occasion: Gear up with phrase packs tailored to weekly consultations or first-time meet-and-greets, so your documentation looks the part.
- Keep your phrase library fresh: Treat your collection like you would your garden; Prune the weeds, and give attention to what works to keep your phrases relevant.
Tip #2: Complete notes during the session – not after
- Do it in the moment: Jot down important information as you receive it. You may think that you’ll remember key details later but no, you won’t. In a bind, you can also use the immediate post-session window too, while things are still fresh.
- Boil down the essentials: Skip the filler and let smart phrases do the heavy lifting. But don’t forget important things like breakthroughs, next steps, etc.
- Bring clients into the fold: Invite clients to chime in on their moment of clarity, capturing a 360-view of the session in their own words.
Tip #3: Make sure you get protected admin time for charting
- Mark your territory on the calendar: Claim your charting domain with a "Do Not Disturb" sign, setting aside those sacred, all-too-necessary hours to commune with your notes.
- Find your own rhythm: See what works for you – marathon sessions or daily sprints – and go with what feels right – and is sustainable long-term.
- Let tech do the heavy lifting: Flirt with voice recognition or digital scribes to turn your spoken word into perfectly written notes that don’t miss out on the slightest detail.
- Leave some time for yourself: Weave self-care into your schedule, ensuring your well-being isn't drowned out by the documentation deluge. A bit of time off also maximizes your chances of writing better-quality notes.
Tip #4: Automate your note-taking
- Go full-on with a virtual scribe: Let Lindy, an AI-powered assistant, sit in on sessions and craft detailed notes that go directly into your EHR, turning hours of typing into mere moments of review.
- Stay present: With note-taking completely off your plate, dive deep into client conversations without the nagging thought of paperwork waiting in the wings.
- Tailor notes to your taste: Lindy follows your lead, allowing tweaks and tunes to craft notes that resonate with your personal touch and clinical standards.
Tip #5: Team up for charting
- Collaborative review for complex cases: Occasionally, consult with colleagues on complex cases to gain insights without compromising patient confidentiality.
- Peer supervision sessions: Use peer supervision to discuss charting strategies and ethical considerations for sensitive information. Without giving anything away, of course.
- Shared knowledge base: Attempt to develop a shared repository of anonymized case studies and charting examples to enhance learning and consistency.
- Interdisciplinary coordination: For patients who are receiving care from multiple specialists, coordinate charting efforts to ensure a comprehensive view of the patient's progress.
Tip #6: Let patients chip in
- Guided self-reflection: Encourage patients to engage in guided self-reflection exercises that can inform your charting, focusing on their therapeutic journey.
- Pre-session check-ins: Implement pre-session digital check-ins where patients can share current concerns or progress, enriching the session and subsequent charting.
- Patient-driven goal setting: Involve patients in setting their therapeutic goals, documenting these collaboratively in their chart to track progress.
- Feedback on treatment plans: Ask for feedback from patients on their treatment plans during reviews, making sure that their perspective is reflected in their chart.
Tip #7: Make templates your friend
- Specialized psychiatric templates: Design charting templates with fields specific to psychiatric evaluations, including symptom checklists and treatment responses.
- Dynamic symptom tracking: Integrate dynamic fields in templates for symptom tracking over time so you can get fluctuations and patterns – develop an overall view!
- Privacy-focused templates: Remember to always double-check templates are designed with privacy in mind – especially for notes that may be shared or accessed by non-clinical staff.
- Try out tried-and-true templates: You don’t have to design everything from scratch. Some top-of-the-line applications like Lindy already come pre-populated with a wealth of high-quality templates for psychiatry. If you’re a little unsure about where to start, this is it.
- Outcome-oriented updates: Regularly update templates to include outcome measures and scales that are relevant to psychiatric care. What you always want is an evidence-based practice.
Tip #8: Set up charting checkpoints
- Dedicated charting days: Establish specific days focused exclusively on updating and reviewing patient charts, maximizing thoroughness without the pressure of a million appointments.
- Progress review checkpoints: Set regular intervals for reviewing patient progress documented in charts, aligning with treatment milestones or changes.
- Compliance audits: Aim to conduct periodic audits of your charting practices to make sure that you’ve got perfect compliance with legal and ethical standards specific to psychiatric care.
- Always keep yourself educated on charting practices: Engage in ongoing education and training on best practices in psychiatric charting, incorporating new insights and methodologies as they appear.
Streamlining psychiatric note dictation with Lindy
We’d mentioned this above, but it merits repeating. It’s time to ditch the pen and paper and really bring your practice into 2024 with Lindy, the cutting-edge medical AI transcriptionist.
Here’s how Lindy can help you:
- Seamless EHR compatibility: Lindy fits like a glove with your daily routines, especially if you're using major EHR systems like SimplePractice. It's about making your workflow smoother, not adding extra hurdles.
- It knows the lingo: Lindy already has ample knowledge of psychiatric and broad medical terminology. It understands even the most complex jargon straight out of the box. Lindy also understands dialects and accents, so fuhgeddaboudit if you think you’ll run into SNAFUs.
- Direct dictation into notes: After your sessions, just hit record and speak your observations. Lindy's smart enough to organize your spoken words into the right sections of your psychiatric notes – with over 99% accuracy.
- Effortless review and edits: Tweaking and perfecting your notes doesn't mean jumping through hoops; do it all within your familiar EHR landscape.
- Support for the learning curve: For those who are still in training, Lindy can archive session dictations for supervisor feedback, aligning with many educational program needs.
- Effortlessly secure: Patient confidentiality matters. Lindy is HIPAA and PIPEDA-compliant (for the Canadians among us). All information is absolutely secure – Lindy will never use it for anything.
- Dictation beats typing: Speaking your notes into existence with Lindy is way faster than the old hunt-and-peck. Trust us, your wrist will thank you.
- More hours for what matters: Those saved hours? They're yours to spend - more time with clients, more downtime for you.
How to make the most out of Lindy:
- Embrace a post-session dictation habit: Making note dictation a straight-after-session routine keeps the details vivid and makes the integration of AI feel like second nature.
- Customize Lindy to your dialect: Tailor Lindy to recognize your frequently used clinical terms and your unique workflow, making it even more accurate.
- Regularly review your notes: Give the notes Lindy drafts a look-over now and then. Spot an inconsistency? Adjust your dictation habits or tweak Lindy's settings for a seamless fit.
- Keep summaries succinct: Go for brevity and clarity in your dictations, focusing on summarizing the session effectively.
- Expand Lindy's role: Beyond note-taking, explore how Lindy can assist with drafting emails, treatment plans, or other documentation, further freeing up your time.
Adopting Lindy for psychiatric note dictation is not just about adopting the latest and greatest tech. It’s about putting your energy back into your main focus: Providing top-notch mental health care for your patients.
Summing up
These 8 tips to make charting more manageable for you are all about making those quality-of-life changes.
Don't let the ever-increasing documentation demands of this field get you down. Try out some of these time-saving tricks to get your notes completed efficiently.
With a few adjustments to your workflow, you can get your notes done and have more time for the important therapeutic work that called you to this profession in the first place.
And, if you ever want to take the next step and streamline things even further, there’s always Lindy!
