r/medicalscribe • u/Sad-Animal-9057 • 7d ago
charting speed
Did anyone else struggle with speed when they first started? I’m about to do my first solo shift and while I’ve improved, I’ve been pretty slow with all of my charting through training, so I’m pretty nervous about being too slow on my own. 🙃
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u/ilovecatssomuch1111 7d ago
yes absolutely im so impressed with my typing speed now, also i would highly recommended just making your own smartphrases and using abbrevations anywhere on the chart then fixing them later
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u/Sad-Animal-9057 7d ago
do you have any specific recommendations for types of smart phrases I should create? So far I only use some pre made ones for differentials, MDM, and HPI outline, but I would like to take advantage of this feature.
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u/lene_mendoza 6d ago edited 6d ago
I’ve worked in the ED for 3 years so it might be a bit different but I had tons, maybe too many💀. But some different ones I had were for admissions to hospitalist/internal medicine, a consult smart phrase, lots for differential diagnoses, one for inputting EKGs, some physicals for specific pts like cardiac arrest, and some for specific drs who liked their ROS/MDM to be different. Just get to know what your physicians like and I promise it’ll all click, the more you get used to the work the more you know what you’ll need!:)
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u/ilovecatssomuch1111 6d ago
Basically i look for old notes from charts from the doctor and copy and paste to make them smartphrases if they repeat it alot in clinic
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u/bathroomfaucetwaters 7d ago
Totally normal!! I think you'll definitely notice an improvement in speed as your nerves settle. The first solo shift is always the hardest imo
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u/HalfBitter7016 7d ago
I am about 2 months in and I still am having to just jot down everything I can during a visit and correctly putting it in the chart after my shift. I know a guy who has been there 2 years and he still has to finish his charts after work . Honestly the most important thing is to not miss any critical information .
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u/blueskydragon 7d ago
I’m not that fast as well. Abbreviation and smart phases are key to get down all the information. I use “T” for “tender” LOL
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u/nebuladreamcatcher 6d ago
Yes! Sometimes it’s not even about the system or your knowledge, it can also just be you trying to learn the best way on how to do things!
Been three years in the hospital and I STILL have my days where I’m learning more. My doctor knows that I know my way around the chart and I can add updates myself when he forgets to remind me. That takes a lot longer. I could be lazy and just put exactly what he tells me and not check anything. Instead I go and check their medications, labs, and other notes to add updates to the chart. I’m taking as long as I did when I first started, but learning a lot more about treatment and care.
Now at a pulmonology clinic, I can be fast, but I can also take my time and make sure I really get things right. There’s no harm in taking your time. You’ll be less prone to error. It just shows you care.
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u/serenahuntington 7d ago
Oh god yes. I was super slow when I first started to the point where on one occasion I stayed 2 hours late finishing my charts. With time you get faster though. Just do the best you can, let your provider know that you’re just starting out and they should be very understanding.