Patient after patient, note after note. Documentation follows you home if you don't stay on top of it between encounters.
You're a family medicine physician seeing 20-25 patients a day. The clinical work is why you became a doctor. The documentation is why you stay late.
You're at your desk before the first patient, reviewing today's schedule in the EHR. Mrs. Patterson's A1C came back at 8.2 and you need to flag it for discussion. Mr. Okoro's lipid panel needs a note. You hold the hotkey and dictate chart prep notes directly into each patient's record. Steno's profession-aware vocabulary handles the medical terms without stumbling. Hemoglobin A1C, LDL cholesterol, metformin, atorvastatin -- they all come through clean.
"Review A1C of 8.2, up from 7.4 in January. Consider titrating metformin to 1000 mg BID or adding a GLP-1 receptor agonist. Discuss lifestyle modifications and check adherence to current regimen."
Review A1C of 8.2, up from 7.4 in January. Consider titrating metformin to 1000 mg BID or adding a GLP-1 receptor agonist. Discuss lifestyle modifications and check adherence to current regimen.
Your first patient is a 52-year-old presenting with exertional dyspnea and bilateral lower extremity edema. You examine the patient, form your assessment, and step out of the room. In the hallway, you hold the hotkey and dictate the encounter note while everything is still fresh. The whole SOAP note takes ninety seconds of speaking. Steno runs entirely on your device -- nothing leaves your Mac -- so patient information stays private by default.
"Subjective: Patient reports progressive dyspnea on exertion over the past three weeks, now occurring with one flight of stairs. Bilateral lower extremity edema, worse in the evening. Denies chest pain, orthopnea, or PND. Objective: Vitals stable, BP 142/88. JVP elevated at 8 cm. Bilateral pitting edema to mid-shin. Lungs with bibasilar crackles. Assessment: New-onset heart failure, likely HFpEF given preserved ejection fraction on prior echo. Plan: Order BNP, chest X-ray, repeat echocardiogram. Start furosemide 20 mg daily. Sodium-restricted diet counseling. Follow up in two weeks."
You have three minutes between patients. The medical assistant is rooming the next one. You pull up the last two encounters that still need notes and dictate both. A URI with a five-day cough. A diabetes follow-up with well-controlled sugars. Each note takes under a minute of speaking. You're caught up before the next patient is ready. No pajama time tonight.
You're eating a sandwich with one hand and need to get a cardiology referral letter out for the morning's heart failure patient. Typing a formal referral letter while eating is awkward. Dictating it isn't. You hold the hotkey and talk through the clinical summary, relevant history, medications, and what you're asking the cardiologist to evaluate. Three minutes of speaking produces a complete, professional referral letter ready to send.
"Dear Dr. Nakamura, I am referring Mr. James Whitfield, a 52-year-old male, for evaluation of new-onset heart failure. He presents with three weeks of progressive exertional dyspnea, bilateral lower extremity edema, and bibasilar crackles on exam. BNP is pending. His medical history includes hypertension, hyperlipidemia, and type 2 diabetes. Current medications include lisinopril 20 mg daily, atorvastatin 40 mg, and metformin 500 mg BID. I have started furosemide 20 mg daily. I would appreciate your evaluation and recommendations for further workup and management. Thank you."
The afternoon block is back-to-back. A pediatric well-child visit, a follow-up for a patient on warfarin, a new patient with migraine. Between each encounter you step out and dictate the note. The warfarin patient's INR is 3.8 and you need to adjust the dose -- you dictate the plan and the patient instruction in one go. Steno handles "INR," "warfarin," "PT/INR," and "subtherapeutic" without you spelling anything out. By 3:30, every afternoon note is done.
Eleven patient portal messages are waiting. A question about a medication side effect. A request for a prior authorization. Someone asking if their lab results are normal. Each one needs a careful, specific reply. You read each message, hold the hotkey, and talk through your response. The tone is right because you're speaking the way you'd actually talk to a patient. Eleven messages done in fourteen minutes. Typing these out would have taken you past closing.
You review the day's notes in the EHR, making small edits where needed. Two notes need addendums -- a lab result that came back after the visit, and a pharmacy callback about a prior auth. You dictate both addendums and sign off on everything. It's 5:45. You're walking out the door on time, with a clean chart and nothing hanging over the weekend. Your colleagues are still typing.
Right after you step out of the exam room, hold the hotkey and talk through the note while the encounter is still fresh. Ninety seconds of speaking beats fifteen minutes of typing at the end of the day.
Referral letters are just you telling another physician what's going on. Talk through it like you would on a phone call. Steno handles the medical terminology and gives you a clean, professional letter to send.
Set aside fifteen minutes and work through every patient portal message by voice. Read the message, hold the hotkey, respond. You'll clear the inbox in a fraction of the time it takes to type each reply.