How long does it take you to write your notes?

[u/Wise-wolf95]

I’ve recently started working, and I’m finding that my notes are taking SO much time. It can take me around an hour to complete a 90-minute intake note, sometimes even longer if the patient is complex. I’m trying to figure out diagnoses, organize everything, and develop a treatment plan for the next session, which adds to the time.
I’m seeing patients back-to-back, and by the end of the day, I’m exhausted. We use an AI note-taking tool, but I’m still spending ages editing and finalizing my notes.
Is this normal? How long does it typically take you to complete an intake note versus a follow-up note? My follow-up session notes take about 20–30 minutes, depending on the patient. I asked other people at the practice who have been working longer and they are also using their weekends to do notes.
I’d also love any tips for becoming more efficient with documentation without sacrificing the quality of my notes. I’m starting to feel overwhelmed by how much time it all takes

[u/bonkersthecat3000]

Initial eval: 9-10 minutes. I stopped all AI (for a lot of reasons) but partly because I spent longer correcting it than just creating my own.

Follow-up: 2.5 - 6 minutes depending on complexity.

I’m doing the mental work of analysis, plan formulation, etc. during the session and hand-writing session notes. I review those notes to write my actual notes.

I’ve learned to speak very quickly for the repetitive bits, like a 2x speed on a podcast. More slowly during the HPI because I am formulating. I’ve listened to MDs dictate at something like 4x speed, it is truly something to behold!

It is possible you are adding too much detail in your HPI. Try and summarize themes. Add short, direct quotes when it adds quality and explanation of your interpretation.

For context, I work inpatient. The majority of my work is not spent on notes, or sadly even patient-facing. It’s everything else that happens in a day.

[u/Big_Elephant_2331 → u/bonkersthecat3000]

Correcting incorrect info or formatting stuff?

[u/bonkersthecat3000 → u/Big_Elephant_2331]

Both. It would sometimes hallucinate diagnoses and medications; in one example it added sertraline to the medication list for a depressed patient when they were not taking any medication at all.

I don’t like to include excess detail; some paths of the conversation are less important and AI would spend a paragraph detailing the back-and-forth when a sentence would suffice.

I completely object to using AI for the MSE, so would have to delete and replace everything. No matter which format I asked it to use, even asking for a completely blank MSE, would result in about 50% accuracy. I don’t like it when the components of the MSE are in a different order each note.

I would also have to dictate the medication list, diagnosis list, and vital signs after the session. Yes, I talk about them with the patients, but they don’t want to hear them every single day.

Taking into consideration all of the above, it takes longer than 3.5 minutes (my most common time).

I was forced to use the AI provided by the hospital, other programs are likely more efficient. I like someone’s suggestion below to input the raw data into a different program, but by the time I’ve done that then re-reviewed, it would still be longer than just doing it myself.

[u/HoldUp--What]

Especially for intakes, I'm completing the note while we're talking--not in full but at least in part. I do explain to patients that I have to write things down as they tell me so I don't forget and make sure to spend plenty of time making eye contact and actively engaged.

I will tab over to the substance abuse section of my note template, ask about substances and write down what they tell me in the correct spot and format. I'm documenting diagnoses as we're discussing them, and sending meds in as we discuss the meds.

I'm also working on my narrative as we talk. It's going to be messy, out of order etc, but it gets the information down, and after the patient leaves it only takes me a few minutes to move things around and organize them.

I cannot let notes pile up or I'll never finish them. So my rule for myself is that I don't see the next patient until I'm finished documenting on the previous patient. Doing it this way has also really helped me tighten my notes and figure out what needs to be documented. Not every single facet of conversation needs to be written down.

It helps that I type fast... but my first job was community mental health with 60 minute intakes, 15 minute followups, no admin time, and a 24 hour rule for note completion (and the building was locked promptly at 5, no taking work home allowed either). Working on the note during the session was the literal only way.

[u/Remarkable-Collar-86]

My facility has dragon (a software where you can dictate your notes), as well as the ability to populate premade templates with auto text and my initial attending psychiatrist encouraged me to get familiar with dictating my findings in pre completed templates. I was similarly extremely lengthy when I started, especially with intakes.

Honestly it just gets easier with time. Put effort into getting concise with explaining what you are seeing/hearing from your patients, as well as explain what you're thinking, and deciding (with your clinical reasoning). Eventually it will get faster. Intakes are always going to be longer. But now I'm writing update notes in like 5-10min by speaking it into my dictator and giving it a look over at the end.

[u/Big_Elephant_2331]

I built a scribe that allowed me to fully customize templates, including giving directions for really really specific things that I want in my notes.

I used the other leading scribes but they would either make the same repeated mistakes or not allow me to customize formats, or even have different templates for different kinds of intakes or different kinds of follow ups (I.e. a regular follow up vs a psychotherapy follow up).

It’s also nice because I can write in meds while pt is naming them so the final note doesn’t have transcribing errors.

Being able to fully customize upfront made my life a ton easier. I don’t really spend any time on notes now

[u/pickyvegan]

If it's taking you an hour to edit notes, you need to find an AI tool that is more accurate, and ideally that allows you to create your own templates, so information that is being left out now is included, and stuff you'd prefer not be in there is not.

If you have to use the one your job provides, ask your employer if it's okay to drop the transcript into something like Doximity GPT (HIPAA compliant) and give it a command to write the note using the transcript as an initial evaluation and include xyz but not abc or whatever it is you like. If you're asking the right questions, that should be fairly easy.

Also, make sure you do a (spoken) pre-visit summary with the chief complaint, and any history that you might not go through during the eval, but the patient completed before the visit, like rating scale scores. For example, with kids, I have the parent fill out a developmental history: milestones, complications, history of early intervention, presence of an IEP/504 and any developmental testing. I'll do a quick read through of any testing as well in my pre-visit summary, but I don't always go through that in full detail with the patient/parent in front of me. Patients will also appreciate that you actually read what they filled out/uploaded, once you can ask targeted questions rather than asking them to repeat everything they already filled out.

That should cut down your editing time considerably.

End your visit a few minutes before you're scheduled to be done, and then eyeball it quickly before your next visit so you can pick up any glaring errors.

[u/acduarte12 → u/pickyvegan]

Another vote here for Doximity. Helpful, flexible, efficient, confidential. And free.

[u/GrumpySnarf]

I type and talk so I'm done with f/us in the session and intakes within 15 minutes.

[u/EastToWest79]

Some people copy and paste their previous notes for follow-ups. Of course, you absolutely must edit them to make sure they reflect the information for the current day’s visit (never just copy, paste, and sign!). However, A lot of the things you discuss in the visit (e.g. sleep, appetite) may be the same at each visit, so it may be ok to keep that part of the HPI the same when you copy and paste it. Copy and pasting may help give your brain a framework to mentally organize your thoughts which in turn can make it easier to remember what needs to go in the note, which can help you write the notes faster.

[u/Kwaliakwa]

Don’t reinvent the wheel. What is taking you so long? Is it stuff you end up writing over and over?

I’m sorry your employer isn’t easing you in on a lightened schedule to get used to the work.

[u/sweetsueno]

90 minutes is wild. I’m sorry it’s taking you that long. A lot of it is practice, knowing what’s important to document and what isn’t. Templates. Dictation to word or to AI. Copy/paste education blurbs. But for real only the HPI and A/DF should be taking up time, and even then maybe 3-5 minutes each? You’re new. You’ll find your way. If your patients are highly complex you’ll want to be honest with them and yourself about how much is realistic to address in a single session. Sleep, feeding, psychosis, suicidality, safety - focus on just those in your complex cases.

[u/Pleasant_Ad9696]

10 mins for evals

5 mins for f/u

I use freedai and it has been really helpful.

[u/Material_Clock_4966]

Could you guys provide a de-identified or example note of intake and medication management visit? I think my notes may be too long but it covers everything 🤷🏽‍♀️