how do I manage a bad employee who I can’t fire?

A reader writes:

For the past 1.5 years, I’ve worked in health care in a very rural area where it is hard to recruit (this is more related to the rurality than to salaries and benefits; salary could be higher but is mid-range, and benefits are good to very good). Due to our service/population, in-person care is important, so I can’t hire remote providers.

I’m the clinical supervisor for several providers, including Grover (they/them), who has been in their position for 10 years and has a very serious issue with documentation timeliness. At its worst when I started, Grover was 300+ notes behind. This is a big billing issue (we can’t bill until a note is completed) and can also quickly become a clinical issue (e.g., if Grover hasn’t completed their last three notes for a patient and something urgent arises, another provider would be in the dark about what’s been going on).

Grover and I discuss/set goals for their progress every single week in our standing meeting. Grover does not minimize this issue, but instead is struggling with (self-disclosed) ADHD and anxiety, and then procrastination related to both. They have made progress at various times: the year before I started, this included eliminating the backlog while on a PIP before backsliding. For the last month, however, they have kept their backlog at around 50 notes. Grover isn’t on a PIP right now, but I have made clear that two weeks of annual leave for a trip this July won’t be approved if they still have a backlog then.

Here’s my issue: I don’t think I would fire Grover in our current circumstances. This was the issue with the old PIP: it was enough motivation for them to reduce the backlog, but not permanently, because we are so short-staffed. Grover provides good clinical care to our very underserved population (although not as good care as care that is appropriately documented!), and I know from an opening we have from another clinician’s retirement that Grover’s position could be open for a year or more. In that time, people’s health will suffer due to lack of access, and that’s not catastrophic thinking on my part. I think Grover will work through the current 50-something backlog, and I don’t think they would take leave that hadn’t been approved, but I still find myself wondering. Do I have options I’m not thinking of? Can Grover’s salary be withheld for failure to complete an essential component of their work?

I am working on the recruiting/staffing issues so that no one is “unfireable,” but those fixes are slow, and this situation leads me to be hesitant to hire anyone I’m not extremely enthusiastic about, because the last thing the clinic needs is another person I’d be hesitant to fire.

The options available to you aren’t great ones.

You can’t legally withhold part of someone’s salary for not completing their work (especially since I’m guessing Grover is exempt, which means you can’t dock pay at all except in very narrowly defined circumstances).

If firing is off the table, all you can really do is micromanage the hell out of Grover to ensure their documentation gets done. For example, rather than just telling them to eliminate their backlog, can you require them to complete a minimum of X notes per day, which you spot-check? Have them spend the last hour of every day in your office, working on notes in your presence? Tell them to notify you each morning of how many notes they plan to complete that day, and report on their progress at the end of the day?

If you’re thinking this sounds horrible for both of you … it really does. But it might be the only way the work reliably gets done — and more reliably than tying it to Grover’s vacation in July, since they might continue to procrastinate until then and then throw up their hands and accept they can’t take the vacation, which would still leave you with the backlog unsolved.

You could also ask Grover what to do. You could say, “I don’t want to fire you, but this isn’t acceptable and nothing we’ve tried so far has worked. What do you think will help?” Or, “I want you to take a week and think about specific systems and practices we can put in place that will help solve this; when we meet next week, please come with at least two ideas.” (For example, what if Grover had 10 minutes scheduled after each appointment ends to use to immediately write up notes? That might affect how many patients they can see in a day … but would that trade-off be worth it if it solved the problem? You’d need to monitor it pretty closely to make sure they were really using the extra time that way; if they’re not, there’s no point.) It might even be interesting to ask, “If you were in my shoes, what would you do?” or “If you could put any policy in place to help fix this, what would it be?”

But yeah. In general I strongly discourage managers from feeling like they “can’t” fire an employee because you can’t manage effectively with no accountability — and after all, Grover could quit tomorrow and presumably you’d move forward somehow — but it sounds like you’re making the calculation that Grover doing 80% of the job is better than no one doing any of the job. I would lean really, really hard into working on those recruitment/staffing issues though.

{ 412 comments… read them below }

  1. Ask a Manager* Post author

    A note to say the LW provided a lot more info here, including that Grover does have time after each appointment for documentation, and here indicating that scribes aren’t an option for their setting.

    Also, note that Grover uses they/them pronouns.

  2. I should really pick a name*

    One thing that might help with the frustration.
    Remember, it’s not that you “can’t” fire Grover, it’s that you’ve made the calculation that for now, it’s better to keep them.

    It’s a decision you’ve made, not one that’s been forced on you, and sometimes that framing can help.

    1. OP*

      This is exactly what I would tell someone else, but hadn’t thought of for myself! Thank you. It is definitely a strategic choice based on how to best serve the community.

      1. Smithy*

        I used to be a fundraiser for a local human rights organization in a country and for an issue that had an incredibly tiny talent pool to pull from for fundraisers. These hiring gambles were increased in precariousness as the organization only really needed one fundraiser.

        The reality was that they were hiring based on promise and who they felt they could become a fundraiser they would work with for X number of years paying Y salary. At which point when they left….if they gave a notice less than 9 months, there’d be a gap where they’d have no fundraiser.

        This is all to say, working a job you know you will never be fired from can some create odd VERY dynamics. And at its worst is when the person who is doing ABC really well but DEF needs improvement, however their manager is also bringing a similar vibe. Of managing some parts really well but similarly letting other pieces slide endlessly. So it can lead to a standoff where you both shrug about how you’re both failing on your own issues but so what – then who will do rural care??? Or that you’re both doing some things well, and hey – someone has to do rural care, and isn’t that the point?

        Being more proactive about the realities and what that means for hiring choices can only help. It may mean that you close the clinic early a couple hours a week just for charting? Or keep the clinic open late a few hours a week for anyone behind on charting? But I do think reflecting that your next hire may also be 80% and then have their own different 20% wildly irritating weakness is very possible. During my time at that NGO, I was hardly treated like a perfect fundraiser. But the second I left, they tore through two bad hires that left me looking like a saint.

      2. Caroline*

        Something else to consider is – apart from getting more micro-managey things in place, which I totally think would be a good idea, ideally with input from Grover – advertising for another position soonish anyway? I mean, people come and go, so if anyone were to leave or get fired or something unexpected happened, you’d want to get ahead on recruitment since it’s likely to take a while.

        If you do that, you can get a head start before it’s really urgent and meanwhile make a concerted effort to make Grover take account of the seriousness of the situation and take responsibility for a very necessary aspect of their job.

    2. Patient safety*

      Your choices Are a: long term patient safety issues did to Grover’s incompetence or b: one year of patient safety issues due to employer turnover.

  3. umami*

    Wow, I wonder if the caseload being given to Grover is … unmanageable? It’s one thing to be able to provide appropriate care, but the documentation obviously also has to be done in a timely manner. I would doublecheck a few things: Is he spending too much time on documentation (i.e. being overly thorough and writing a narrative when a sentence would suffice)?, Is he being fairly compensated for the amount of time he needs to spend on documentation? Is he in need of better time management skills/tools to help him stay on track? Is he seeing more patients in a day than he can reasonably complete documentation for?

    1. Ask a Manager* Post author

      These are all good things for the writer to make sure they’ve reflected on (absolutely!) but I also want us to take the writer at their word that Grover says the problem is being caused by their struggle with ADHD, anxiety, and procrastination.

      1. umami*

        That makes sense. It’s just that sometimes procrastination can stem from feeling overwhelmed as well, so I would want to make sure Grover doesn’t feel like he can’t catch up but also doesn’t feel like he can push back on the workload.

      2. Kyrielle*

        With ADHD and anxiety in play, I also wonder whether Grover has a therapist who might be able to help them brainstorm strategies (without OP’s involvement).

        I also wonder whether writing is easy or hard for them, because sometimes ADHD can include issues that interfere with writing as well. If that might be an issue, there are things that could help – so I would also recommend that, in exploring options with Grover, the LW should also ask whether the issue might be the writing more than the thoughts, and if so whether text-to-speech or something might help. However, given that this is medical and HIPAA would presumably be in play, not all tools might be appropriate – if they send voice clips to a server to sort them out, for example.

      3. Putting the Dys in Dysfunction*

        I have Grover’s issue in that I’m terrible about documentation and taking notes because of my ADHD. What helps me is that to a certain extent I’m able to offload that work onto others who don’t have the same issue; I also use what automated capabilities my workplace has.

        Is there any flexibility, confidentiality permitting, to have others help? Or can Grover dictate his notes over a minute or two between patients?

      4. AlsoADHD*

        To be fair my ADHD flares up much more and I procrastinate more when the workload is too high. Not true of everyone but it’s very easy to procrastinate when you know you can’t finish reasonably and so hard to get started and overcome my ADHD brain when I’m bombarded.

        1. Stuckinacrazyjob*

          nod. my brain just goes BLERGH. now our notes must be in within 24 hours! Sometimes I’m late and once my boss had to put a meeting ( NOTES DUE) on my calendar until I did all my notes on time for a month

      5. River*

        That doesn’t mean the workload isn’t unreasonable. It just means that everyone is overworked and Grover is the canary in the coal mine. Usually when a job is toxic, the disabled people are the first fired bc they are the must unable to cope with unreasonable demands, overtime, bullying, and all the other things that are broken in a broken system.

        1. Ask a Manager* Post author

          Sometimes, and sometimes the Grover is in fact not working as much as they reasonably should be. The OP is better positioned to know which it is than any of us are.

      6. Dog momma*

        I agree. and lets not say that everything reflects on mental health. You can still be successfully employed and do a fantastic job. At what point is it making excuses for employees?

      1. umami*

        Oooh, sorry about that! I should have been more careful, I automatically translated Grover into he. Oops!

  4. Betty (the other betty)*

    Is there time in Grover’s schedule to make notes during/after each patient appointment? That would seem to be the best solution since notes made right away are likely to be more accurate than notes made after Grover has seen up to 50 other patients.

    (I’m not a healthcare provider but the idea that my healthcare provider might be waiting days to write up notes about my visit is disconcerting.)

    I know my doctor friends get burnt out when they see patients back-to-back all day and then need to chart/make notes in the evenings.

    1. TooTiredToThink*

      I’m also wondering if, since Grover has ADHD, would it be feasible to have them records the notes verbally and maybe pay for a transcriptionist? It might free Grover up a bit if they are overworked and keep the notes up to date. Some people are just better verbal processors than they are record keepers.

      1. Dell*

        this sounds like a brilliant idea if it’s workable. Many of us ADHDers love processing verbally.

      2. Ashley*

        A remote transcribe might be an accommodation that could let Grover see more patients.

        1. River*

          Medical transcription is totally a job that exists and used to be very common before internet-connected hospital systems.

      3. Kez*

        In the thread of reasonable accommodations, I know that some people with executive functioning troubles (which encompasses the issues caused by ADHD in this case) find that the part of “doing a task” that is the most overwhelming is starting. Fears of imperfection or of being seen as less-than can sometimes get in the way of getting anything done at all!

        Something I try when I’m faced by this trouble is template-creation. So if verbal processing isn’t an easier option, maybe work with Grover to come up with a few simple “starter” lines for notes. I don’t know your area of practice, but to provide an example here, I’d keep for myself some easily copy-pasted lines with blanks like the following:

        “Patient arrived with concerns about ____ and upon further questions and examination, ____ was determined to be a likely cause.”
        “Patient arrived for follow up and was presenting the following symptoms still: ____.”
        “During regular check-up, patient shared ____ which lead me to suggest ____.”

        I don’t know if this sort of thing would help, but you could put it on the list of “options to explore” if that kind of system would be compatible with the services you provide.

        1. Jessastory*

          yes, as a teacher I’ve found sentence frames to work well for students who have trouble getting started writing. another possibility is voice notes or trying voice to text- Grover would still need to do some writing and editing that way but if they did a quick voice note after each visit, they could use those as memory joggers to complete written notes at the end of day

        2. Garblesnark*

          there are software packages available to hospitals that specifically make these available to doctors that are speciality specific. but, I would be surprised if this hospital doesn’t already have them.

        3. Adelena*

          I already put my thoughs on what could work for (my) adhd, but yes this too! Templates!

      4. TheJoseph*

        Other ADHD tools that could help here are: setting aside that specific time daily with concrete goal of X notes completed; body doubling (someone else physically there, maybe working on notes too); specific location for notes that is different from a social or normal work area.

        1. OhNo*

          I was thinking that if there’s someone else in the office who has administrative tasks to clean up at the end of the idea or between appointments, body doubling would be a HUGE help to me in this situation, and has the benefit of just requiring that someone else be in the same space still working on their own tasks, so doesn’t eat away at someone else’s time to do their job the way having to check and double-check things does.

        2. River*

          I’m using Focusmate to co-work with other people who work best with body doubling. In the free version, you schedule a 30, 45, or 90 minute co-working session over zoom. You don’t talk while you’re working, but you check in at the beginning and at the end. Just having someone else on my screen working on their own thing helps me stay on task.

          1. Mac (I Wish All The Floors Were Lava)*

            I had never heard of Focusmate. A million thank-yous for introducing me to it, it sounds brilliant!

      5. bamcheeks*

        I was a medical secretary for a year and my job was explicitly to type up recorded letters from doctors. They made clinical notes during the appointment (often including frankly hilarious sketches of eg. where exactly the rash was on a pair of hastily drawn legs), and then would dictate a letter to the patient’s primary care provider that summarised the case history, diagnosis and treatment plan, which I and other secretaries typed up, saved in the system and sent to the PCP. This is so normalised in healthcare in my area that I’m actually surprised it’s not the norm everywhere!

        1. Ultra Anon*

          This is one of those jobs that has somewhat vanished due to advances in electronic Medical Records. There are quite a few programs that allow voice to text charting that also allow for the provider to code their own visits. Those charges are held until the dictation is signed off on by the provider, reducing the risk of billing charges without supporting documentation.

        2. Dog momma*

          Now its some sort of an electronic scribe…that many times gets the wording wrong..and the docs still sign off on the notes. Will be a nightmare in a lawsuit bc some of the sentences make no sense!

      6. Cj*

        my Dr dictates notes during my appointment, which i am assuming are transcribed using voice to text, or typed up by an admin.

      7. Reluctant Mezzo*

        Microsoft Word and other programs have lovely dictation modes now. Could that run in the background while they are doing clinical stuff and then they can supplement with other notes? That may require a program where you can add medical terminology to the program’s vocabulary. but it could help. Some people find it easier to talk than to write, and some people find it easier to talk to the nice machine rather than to a human.

    2. Gyne*

      This goes toward decreasing access to care – padding appointment times lowers the number of appointments available each day, which means patients will have to wait longer for appointments because there are fewer openings.

      I’m not necessarily saying that your solution is a bad one, just that it has downstream effects that will impact the patients negatively.

      1. Not Tom, Just Petty*

        I think umami and your comments bring up a bigger issue.
        What is an appointment?
        A therapist hour is 50 minutes. There’s a reason.
        Shouldnt the related paperwork be figured into the appointment?.
        Is it padding the appointment or is it being realistic about what a medical provider can do in a day?

        1. umami*

          That’s the problem my spouse faces. He can technically see X number of patients in a day, but he is paid for a visit, not an appointment. And until he’s there to assess, he doesn’t really know the extent of the need, so there is no standard appointment length, but he always has to leave to see another patient before he can finish the documentation, so much of it ends up being done at home. It sounds like OP’s case is more structured, though, so hopefully there are some usable tips here for keeping Grover motivated and on track.

      2. Observer*

        No one is suggesting “padding” the schedule. They are suggesting scheduling *adequate* time to do *necessary* tasks. Seeing more people is not going to be much help if the person seeing the patient doesn’t have the information necessary.

        This is the kind of thinking that leads to doctors who routinely misdiagnose patients because they can’t “pad” the appointments enough to allow patients to fully describe the problem. Instead doctors often interrupt their patients withing 15 seconds of their starting to talk, with predictably bad results.

        The OP is pretty clear about the problems. If the place can’t bill, the FEWER people will have access than if you cut down the number of appointments, because the place won’t be able to pay all the people needed to provide services. In fact it could be bad enough that the place shuts down, and then NO ONE has access.

        The other problem is that lack of notes means that people get bad care. Whether it’s that the person following up doesn’t have the necessary information (eg person comes in with odd rash, but there is no note that the person was prescribed a new medication last time the person was in, so the provider doesn’t even look for side effects of medication) or necessary followup doesn’t happen (eg someone comes in and has a throat culture, but there is no note so no one follows up with the person who has strep – and winds up with scarlet fever for no good reason. They might as well not have had any access for all the help it did them.)

    3. umami*

      That’s my partner. He spends all day seeing patients because … he can *see* that many patients in a day, so they tend to overassign him. But then he spends evenings and weekends completing documentation because that part takes so much longer! It’s not really sustainable, and he’s also ADHD, which means he has to take frequent breaks and can physically/mentally only spend so much time on that task.

      1. mercedenne*

        My partner also works in healthcare, and her clinic provides a massively needed service to an underserved/rural clientele. The doctors she works with see, on average, 60+ patients between 2 doctors each day. This practice is a particularly high-stakes specialty, where late notes might be the difference between life and death. She inherited a stack of notes that were at least 3 visits behind. She commutes 2 hours each day, charts for a few hours at the location, comes home and charts into the wee hours of the night. She also has ADHD, so the hyperfocus goes to her notes and household tasks/anything beyond basic self care gets thrown on the wayside until the weekend. Healthcare is so exhausting.

    4. eye roll*

      I’d also wonder if Grover can write notes DURING the appt. My provider pauses several times to record their notes and writes up final comments about the visit while I’m getting my stuff together to leave or at the counter outside the room if I’m dressing.

      1. Katherine*

        Concurrent documentation can also be clinically helpful, at the end you review the session with the client and jot down an outline, and that summary can be very useful. In mental health the transparency can be really helpful as well because people really do worry about what their provider is writing about them. If they realize the documentation is something like “discussed stressor and client identified 3 coping skills” they can often open up more because they realize you aren’t writing down personal details or judgements.

        1. anonagain*

          I like this idea of reviewing the note with the patient. It adds immediacy and a concrete patient-centered motivation for the task. This would be helpful for my particular flavor of ADHD.

          1. Grumpy Elder Millennial*

            I figure the notes would also be more accurate this way, writing them up before there’s a chance to forget.

        2. Lala*

          All of my providers always chart while I’m in room at the end of my appointment. Didn’t realize not doing it this way was a thing!

          1. Megan*

            Same. It seems very odd providers aren’t just typing as they go. In our region it’s normal in both hospital and clinical settings. My kids have never had an appointment where a laptop wasn’t present. They actually have giant rolling computers in our hospitals.

          2. MCMonkeyBean*

            Yeah, obviously I don’t know if they make more notes later as well but I am usually even sent home with a copy of the notes made during the visit!

        3. Reluctant Mezzo*

          I would love to be a patient to a doctor who did that! Then I could add, ‘but I said the pain was over ‘there’ not where you wrote it was’. That would be a bigly good way to catch any communication errors.

      2. Sloanicota*

        I was thinking this too. If Grover is an otherwise good employee and OP wants to retain them, then can we think outside the box about how to help get these notes in the system? Yes, training on doing them during the session would be great. Or what if Grover can dictate the notes through the phone or a transcription service? What if Grover has a part time assistant who types up or receives verbal notes? Anything else in this vein? Don’t dig in on forcing Grover to do something they’re apparently ill-suited to do, find creative ways to get what you need.

      3. Regina*

        I think this idea could really help! It has helped me as a provider and I know it’s been helpful for some people that I work with. I also have a suggestion that a coworker of mine told me has been enormously helpful with their own delinquent notes: Make a deal with yourself that you have to write SOME kind of note for each patient by the end of the day, but it doesn’t have to be a GOOD one. Mediocre notes are better than no notes.

        1. MCMonkeyBean*

          Personally, deals with myself never last more than a couple of days. I’ll be like “hey if I do this thing then I can eat cookies tonight.” But then I know that really I can just eat the cookies anyway lol.

      4. Formerly Ella Vader*

        Can a helper attend some appointments and write notes, which Grover could check over later? Whether it’s someone whose current job title indicates that they’re learning towards becoming the same job title as Grover (an intern or student?), or someone whose job title would be like clerk or recorder or scribe. I bet there is provision for this kind of role in your health privacy legislation, for a provider who is vision impaired or dyslexic – and if it’s not a situation where the vulnerable patients are unlikely to give consent because of past trauma or whatever.

        Sometimes I can’t start a writing task, but reading someone else’s imperfect version kicks me into being able to edit it. For other people, hearing it might work better than reading it.

        It sounds like Grover is good enough at other parts of the job that it might be worth looking for a way to decrease the proportion of their time spent on the hard paperwork parts.

    5. ferrina*

      ADHD person here! Depending on how Grover’s ADHD works, it may be really hard for him to go back and forth between patient care and charting. ADHD often feels like different mindsets and you have no way to switch between them- my Multitask Mode allows me to work on a lot of different things and urgent timelines, but I can’t get into details, nitty gritty, or admin. When I’m in hyperfocus, I can do a deep dive into whatever I’m working on, but I can’t be interrupted to talk. I cannot switch between them. It takes at least 20 minutes, and sometimes just won’t happen. When I have a People-heavy day, I do my best if I’m in Multitask Mode and I’m happy to interact with people a lot (6 hours? no problem). But I can’t take a 15 minute break and focus on paper- I just can’t switch gears like that.

      Grover may need to experiment with their ADHD and see if it feels better to chart immediately after/during patient visits, or if it’s better to have a block of time later in the day (with a break time worked in). I’ve also found that I need external triggers to activate my hyperfocus. For me I need to turn on a CD (and it must be a CD- radio/streaming is too distracting, silence isn’t distracting enough). If Grover knows what their are, do what you can to support that.

      1. Kez*

        Thank you for describing this element so clearly! I definitely observe this in my own friends and family with ADHD, and sometimes playing with a schedule in this way can help alleviate the pressure to constantly switch mindsets. OP, it might be worth experimenting with Grover providing x number of appointments back to back and then having a y minutes break followed by z minutes of “notes time” or some other schedule that Grover would be willing to try and which would fit into your service model.

  5. umami*

    Another question I have is, is the care in a facility, or in-home? Just wondering if part of his time is spent traveling, since OP mentions it is a rural area. If he’s spending chunks of time going from patient to patient, it might not be possible to see as many clients and still get all the documentation done in a timely manner. Regardless, I would definitely not continue to assign him more visits until he can get caught up and develop a working system to get his notes in on a weekly basis.

    1. Goody*

      Tying into this – if he’s a traveling caregiver, maybe he could dictate his notes to a cassette while he drives. An office admin/secretarial position is likely an easier hire than a clinical, and that person could be tasked with transcribing the cassettes so then he just has to review, maybe edit, and sign off. This could still work if all clients are at the same location, just not with as much “down” time between sessions.

      And yes, definitely build in some dedicated office time for documentation, setting schedules, etc.

      1. umami*

        I like that idea of dictating notes! I’m going to suggest that to my spouse because he is always driving between patients and tends to get on the phone to occupy his mind, but this sounds like a really effective use of that time!

      2. Healthcare Manager*

        Just a reminder, Grover’s preferred pronoun is ‘they/them’.

  6. CanRelate*

    I’m not at all familiar with the ability to do this in health care, but is there anyway to hire part time help that doesn’t have to be as qualified but can help do the wrangling? Like, an assistant?

    It may feel odd (and maybe impossible) to do this as it may feel like a “reward” the behavior, but with this many circumstances working against you, and this person who is trying, but perhaps just incapable of this task, the best solution maybe to find a way to just have someone help with the pure mechanics of their organization and have that be their sole responsibility.

    1. ThatGirl*

      In this case, I don’t know that it would help – Grover needs to write the notes because Grover saw the patient. Only a clinician is generally able to do that.

      1. Gyne*

        I’m in healthcare- I actually think CanRelate’s solution is a good one. Many doctors work with scribes who essentially write the note for the doctor, then the doctor reviews and signs off on the note.

        1. ThatGirl*

          The scribe would have to sit in on the appointment though, right? Or at the very least get notes directly from the doctor at some point?

          My perspective is that my husband is a mental health clinician, and I know he needs to keep up with his notes while it’s fresh in his head.

          1. word nerd*

            There are virtual medical scribes who can be present during appointments, and the doctor might make comments out loud as they go. But might not work as well for therapy.

        2. CanRelate*

          Yeah I wasn’t sure if this was possible due to confidentiality needs, and wouldn’t be surprised if the other person would need to be just as qualified to accommodate that.

          If it hits the same problem of needing to find a skilled worker would make this pretty dead in the water, but it seemed worth contemplating.

          I would, even if that’s not an option, think about dictation software or anything else that might help with the writing part of the task, anything to reduce the initial friction can help someone with these time management hurtles.

        3. MMB*

          Yes. This is what I was thinking. If he has self-disclosed Anxiety and ADHD a reasonable accommodation (provided that the diagnosis is confirmed and the funding is available) might be to hire a part-time transcriber or even a full-time transcriber who can help Grover stay on top of their notes and possibly even help free up some time for other providers.

    2. Dell*

      Yes, and this assistant could transcribe for more than just Grover, too, if the workload allows and other employees would also prefer verbal dictation. It could be a win-win.

      1. I'm Just Here For The Cats!*

        If it’s not possible for the assistant to do the note, then maybe they could help keep Grover on task. Like making sure they have enough time in the day to complete the notes, and that they are not disturbed, etc.

    3. Loopy*

      As a patient I’ve seen this scribe approach taken. The scribe wrote all the notes and doctor just signed off. They did a pre appointment session with me to get down initial info (this was actually more just the beginning of the appointment but doctor hadnt come in yet) and then also sat in.

      But I wonder how easy it would be to hire a scribe since hiring is already difficult in that area. You might have a bigger candidate pool for a scribe??

      1. ronda*

        yes, the surgeon I just had did have someone taking his notes for him during my appointment. I am not sure what the qualification are for someone doing that, but it is a possibility.
        It would also depend if it is cost effective. I think this surgeon is able to bill out lots of $, so worth it in his line of business, maybe not in less profitable visits.

  7. Dawn*

    Maybe I’m just summarizing a bit, but if you can’t actually fire them, the only thing you can really do is make it more painful for them not to complete the work than to just give in and complete it.

    As someone who suffers from similar issues myself, sometimes literally the only way to get motivation is for the alternative to not getting it done to actively and imminently suck more.

    I’m not a fan of treating employees punitively, but your best option – and Allison already offered some good ones – is to start brainstorming what would be less enjoyable for Grover than simply completing this work and then actioning that until doing the work becomes a habit.

    1. AngryOctopus*

      Yes, maybe if there’s no travel buffer involved, make sure that right after Grover has an appointment, they sit down for 10′ and write notes. Does that mean you (at least at first) may have to hover outside the door and then hover over them to make sure it gets done? Probably. But if this is a good way to light the “get it done now” fire, then perhaps that’s the way to go. And I do agree with Alison that asking them “what do you think might help?” can also help with giving them more ownership over the solution to the problem. OP, I have confidence that you can work this out together! You just may have to get a little more overbearing in the next 3-6 months than you normally would!

    2. Sylvan*


      Same diagnoses as Grover here, FWIW. Clear goals and consequences help. I wouldn’t recommend going to this approach *first*, but this problem has been going on for so long, other approaches haven’t worked, and your patience must be wearing thin!

    3. Chutney Jitney*

      Ugh, no. Please do not use negative reinforcement on yourself or anyone else. You’re just reinforcing that the task is awful and everything around it is awful, so next time you’ll just procrastinate harder while feeling even worse about it.

      I think the best option is to find out what the barrier is and find out how to remove it. Are they afraid they’ll forget something so put it off (likely meaning they *do* forget)? Do they dislike typing? Do they tell themselves it will be easier later and then later comes and it’s not? Do they work better in the morning but are typing notes at night?

      Would appealing to their role/authority help? Like: completing the notes helps the patients, you know how much you like helping them. Or Jane can’t get her PT appointment without your notes, she’s depending on you. Or other provider completed more notes than you – you can’t let that happen!

      1. Dawn*

        Sorry but reminding myself what the consequences will be if I don’t get something done today works for me, and does not actually result in my finding the task or everything around it awful. That isn’t necessarily the same thing as “negative reinforcement” either; sometimes “people are depending on you” is exactly what the “consequence” is.

        But some of this is soft-pedaling it a little much for a manager who has presumably already tried those things, and also whose job it isn’t to manage someone’s emotions.

        Thank you for your recommendation, but this is what works for me and has done for many years.

        1. Dawn*

          And here, for the record, is an example of what this looks like for me:

          “You don’t feel like going and picking up your prescription tonight? Ok, that’s fine. But you will have to do it tomorrow, which means you will still have to get dressed and ready to go out and you’ll be on a tighter timeline tomorrow. Or you can spend the 15 minutes now and that’s not a problem anymore. Plus you’ll have your medication stocked in case something actually goes wrong and you’re not able to pick it up later.”

      2. Stuff*

        Actually, for a lot of us with ADHD, negative reinforcement can be extremely effective. It sucks, sure, but my brain is what it is. I can’t really pretend that what is generally the most effective solution for me isn’t a solution just because it is deeply unpleasant and humiliating.

        1. Data Bear*

          But there are also a lot of us for whom it is deeply counter-productive. My guess is that Grover is probably in that camp, given the history, but we shouldn’t assume one way or the other.

      3. Ellis Bell*

        So there’s an ADHD blogger who calls it “the panic monster” and has comics about how it’s the only way to keep the ADHD monkey in line. As someone with ADHD I concur strongly with panic monster theory! I’ve actually even chosen high pressure, constant deadline professions because more “panic” actually feels really good and productive to me. You’re right that it should not actually be “negative reinforcement ” though! The panic monster merely shows up when a deadline is fixed and unavoidable without consequences. So, if it’s comfortable, or possible to put it off until tomorrow, you will. I have learned how to set my own mini deadlines before the big deadline, but it took years. The OP could totally be the hard line, here.

        1. TeaCoziesRUs*

          Yes! Wait But Why created the cartoon initially and it is AMAZING. I’ll link in the next comment.

      4. MCMonkeyBean*

        Yes, especially since it sounds like Grover agrees this is a problem and would like to work with OP to fix it! There are many things you can try before you get to “punishing” them. As someone with ADHD I’ve seen many great suggestions in this thread already that may help, including things as simple as more concrete deadlines. I know for me personally if you tell me “you have to clear this backlog of notes” but it’s like a long project with no deadline, there is no feeling of urgency that would make me pick that up in my spare moments. But if you say “you need to clear 15 backlogged notes per week” then I will probably get it done (at the very last minute on the last day of the week lol, but it will get done).

    4. Somehow_I_Manage*

      The problem with this approach is that that if LW puts the screws on Grover to increase their pain, they may just quit- which is not a desirable outcome for LW. Sounds like even with their limitations, Grover is employable and hard to replace.

      I think the main way to deal with this is to redouble recruiting over the long term, and try to marshal resources to work around Grover’s limitations in the short term.

      1. constant_craving*

        It’s certainly possible, but I doubt it’s likely that Grover would quit. Timely notes is an essential professional competency for mental health and medical fields. They are likely to have a tough time getting hired elsewhere with this track record and likely know it.

        1. SW*

          Oh yeah, that’s the logical outcome and that may deter some people. But that’s a future worry compared to the pain and the embarrassment of the current moment.
          Odds are that Grover has had hundreds of interactions like this over their lifetime which have helped create the anxiety and procrastination and can then fuel those issues further. It’s easier to just give in and go “guess I’m just a failure… again!” than to battle with your brain every single time because it just won’t let you do the work, even if it sinks your career. Yeah it really sucks for everyone involved.

    5. ferrina*

      Not always. I have ADHD, and while it’s true that punishment can up the ante and get the work done short term, and a certain point I just *can’t*. My brain stops and refuses to move a step further. This may be especially true for Grover, since they have both ADHD and anxiety. Jessica McCabe (ADHD expert and ADHDer) calls this the Wall of Awful. I’ll put a link to her great explanation video in a reply. Pretty much a seemingly simple thing becomes The Thing of Impending Doom due to a combination of mental block, negative associations, and not having the mental tools to tackle The Thing. For ADHDers, it’s pretty common for The Thing to be life admin, because that kind of executive function is can be extremely hard for ADHDers (it’s also common for only some life admin to be prohibitively hard and other parts to be fine or even easy- ADHD is like a mental cat and does what it wants)

      Supporting the person through The Thing can help with long term results. It’s starting to break down The Wall of Awful- the goal is to remove the fearful associations. So this might include sitting with someone while the do The Thing, checking in on them, or encouraging them to try different strategies. It’s about support, not punishment. I’ve noticed that this has better long-term outcomes for me, and I’ve used it with a few other folks as well (both ADHD and non-ADHD; part of my role is training). When we roll out a new software, there’s always someone who doesn’t want to adopt. I could force them to log in with threats, but if I have them screen share with me for 30 minutes as they explore it for the first time, they’re more likely to use it long term.

      Caveat: the person has to want to address the behavior. You may not always know what this looks like in ADHD. Sitting and staring at the screen doesn’t always mean we don’t’ want to do it; it could mean our brain is avoiding it or processing information. It’s pretty much impossible to tell from the outside. A few ways you’ll be able to tell is that over time, Grover will get more done (not all, but more). It will likely come and go in waves. He will suggest strategies to try instead of you needing to constantly suggest thing.

      One last weird quirk: it may be that the best way for Grover to do the charts is to do something different with them every few months. This is how I keep track of the dozen projects that I’m on–I switch organizational systems every 3-6 months. The new system keeps my brain entertained and engaged and I can focus on the projects again. Of course, every ADHD is different, so Grover will need to find the strategy that works for them.

  8. Batmaniac*

    One of the items that jumped out to me was your reference in the second to last paragraph to the short-staffed nature of the whole practice. Is it possible, rather bringing on another clinician (since Grover’s clinical care is apparently good) to bring on some type of office administrator who can handle notes for multiple clinicians, freeing them to potentially take on a larger client load to alleviate some of that burden? This may be a situation in which you can simultaneously address your short-staffing and relieve existing staff of tasks at which they struggle.

    1. I'm Just Here For The Cats!*

      I don’t think having a 3rd party doing the notes is going to be the answer. Depending on what type of clinician Grover is there’s not going to be much that person would be able to do without having been in the room and maybe a requirement by the licensing body or state that they are the ones completing the notes. I’m thinking like a mental health counselor would only beable to complete the notes because they were the ones in the room with the patient and listening to what the patient said.

      Now if Grover recorded himself talking about X Y Z and then someone transcribed it into the note for him that might be a better option.

  9. Keelie*

    Some (many?) practices use scribes for this purpose. This may have already been discussed, but it might help. I worked for a time in a Workman’s Compensation practice and their deadlines are very tight, they don’t get paid if they miss deadlines. We had one physician who would not allow the medical assistants to do vital signs (he said “they take too long!) This meant that the insurer paid a lesser amount for that visit. So, they hired a scribe and that helped tremendously. Some places use medical students, etc. for this but we used medical transcriptionists because soon many of them lost jobs to voice recognition. Maybe this could be an option?

    1. word nerd*

      I would add that virtual medical scribes are also an option since this is a rural practice.

    2. Hapless Bureaucrat*

      I was coming to make this suggestion, along with “build in time at the moment to note.” Having someone who can transcribe or enter casenotes could benefit more employees than just Grover!
      Look at this as a supportive employment issue– given their diagnosis and history Grover is likely to continue to struggle with casenotes, and solutions like withholding leave or PIPs are patchwork solutions in that the level of performance Grover exerts to meet those is likely not sustainable. So which are the specific barriers? Forgetting afterwards? Boredom with the task bombing executive function? An anxiety block at the hands-to-keyboard portion of the job that transcription or text to speech could solve?
      If you’re able to find creative solutions here, that’s something that may make you more competitive in future recruiting too.

  10. Veryanon*

    Some ideas:
    1. Schedule admin time for Grover so that they can type up their notes every day. Maybe work up some simple macros or templates that could be used for situations that occur frequently, to lessen the work.
    2. Have Grover dictate the notes after every visit on their phone or a voice recorder and hire someone to transcribe them daily. Maybe Grover struggles with organization and this might be better than having them do the typing/inputting.
    3. Review Grover’s case load and make sure it’s not overly demanding. Are the other HCPs getting their notes done timely? What are they doing that Grover isn’t? Get some tips and tricks from them about what has worked for them.

    1. Veryanon*

      or voice recognition software that would convert Grover’s notes into text.

  11. Heidi*

    Could there be a way to support Grover in treating their ADHD and anxiety? It seems like the solution that offers the best chance of Grover being able to stay in this role without burning out.

    If it is at all feasible, you could consider hiring a scribe to do the documentation. A lot of ERs and other health care systems have someone in this role. It doesn’t take all of the documentation burden off the provider, but it can offload a good deal of it.

    1. Heidi*

      I also used to know a provider who would dictate his notes at the end of a visit in front of the patient. It’s not something I’ve seen anyone else do, but he liked it because the patient could hear again what the recommendations were and could correct the record on the spot if necessary. I would not recommend this for most people, but this seems like an extreme situation (300 notes in the hole!) that might require some out-of-the-box thinking. Perhaps Grover will find it easier to get things done if the patient/client doesn’t leave until it’s done. They’re the ones who stand to be harmed by not having their visits documented, after all.

      1. My Cat’s Human*

        Hmmm….this is an interesting option. The client essentially becomes the ‘body doubling’ person that is often effective for keeping ADHD’ers on track. If Grover is going into the clients’ homes, having to finish that appointment’s notes right there – and not hang out in their living room forever :) – would be a good thing.

  12. Dell*

    As an ADHD person myself, anecdotally we are much more able to handle short deadlines (like the end-of-day or end-of-week ideas) and we are generally much more motivated by positive rewards than by negative ones. I hope that helps brainstorm some workable solutions.

    1. Hawk*

      Seconding all of this. If I get punished for not doing things, the guilt overwhelms me more than not doing them and I will never get them done. (I have ADHD/anxiety)

      1. Shorty Spice*

        Yes this is what would help me as someone with ADHD: external accountability that is checked frequently.

        Maybe you need to have a daily check in where they confirm all notes are up to date? Or weekly if that’s not workable for you with your own case load.

    2. Stuff*

      I’ve had exactly the opposite experience. Positive rewards are completely ineffective, because I just accept I’m too incompetent and stupid to ever earn those rewards, and come to terms with not getting them. Negative reinforcement is an excellent approach for me, it actually motivates me to extract my head from my ass, at least for a while, and I am much more likely to maintain expected behaviors if I’m going to be harshly punished than if I’m offered a theoretical reward I never expect to see.

      1. Ellis Bell*

        I’d actually go with both carrot and stick. I’d also make the positive reward rather small but achievably rewarding; something pleasantly integral to the task, like discussing the work done and the deadline met; briefly processing some details verbally with Grover (ADHDers often like that),and just really underlining the fact that they met the deadline (rather than leaving them under the impression that it was just one footnote to the big deadline). There is no bigger reward to an ADHDer who is often chasing that feeling of “job well done on deadline”.

    3. cncx*

      Not diagnosed (but am definitely neurospicy) and daily/Friday cob deadlines work best for me, too. A July deadline wouldn’t make a dent.

      1. Gamer Girl*

        Same–finally someone said it! July is waaaaay too far away, OP! You need to make the deadline today. X amount done by COB each day, til it’s done. Otherwise, no way Grover is making that deadline til 11:59pm June 30th!

        Also, there’s literally no reason to make this punitive. Ask for it. Every day. ADHDers already have incredible amounts of shame and do NOT mind being asked repeatedly for things and being expected to provide a real answer. Tell Grover that you see they’re in the shit, tell them you acknowledge that, and that to close the gap, they will do a minimum of X amt per day, every day, in the short term.

        In the mid to long term, get a virtual medical scribe. It’s a completely reasonable accommodation, ADHDers love verbal processing and generally have few problems talking to someone/dictating notes. And, it’ll free Grover up to possibly take on a few more patients. If they are really great at their job, why not try it? My guess is that these accommodations will make Grover and you able to do the work far more easily and efficiently.

  13. Peanut Hamper*

    As someone who also has ADHD and anxiety, I have found the Pomodoro technique to be highly useful to my getting things done. The use of a timer does amazing things. I would break up that hour into two pomodoro sessions and see how that helps.

    If you get a pomodoro app, many of them can make a ticking sound, which also helps, although it may add to your anxiety. YMMV.

    1. umami*

      My spouse literally has an hourglass on his desk that he uses. It’s helped him a lot.

    2. Ellis Bell*

      Oh timers are classic and should always be the first move out of the gate. If Grover hasn’t tried this yet, they should.

    3. ADidgeridooForYou*

      Loooove the Pomodoro. It’s still an arbitrary deadline, but somehow it feels more real seeing it on my computer screen.

      1. Peanut Hamper*

        Yep! And it helps with the anxiety because you know you only have to deal with this for the amount of time that the timer is running, and then you can give yourself a break and think about something else. Five minutes on watching tortoises eating strawberries on YouTube can sometimes be the thing that takes you away, now that Calgon can’t do that any more.

  14. rachel*

    Not sure what type of provider this is, but is there an ethical complication for their license, potentially? I know that I was trained to finish the note IMMEDIATELY AFTER the session (which I definitely don’t always do), but, there could be something bad that could happen and maybe Grover could lose their license to practice if they do not adhere to the standard for their profession? It would be helpful for Grover to help them change this bad habit!

    1. rachel*

      Also, to reply to myself, could the office provide some documentation training to help Grover learn how to quickly pull together a serviceable note? this may really help with perfectionsm- a note that is legally/ethically “OK” but not perfect is much better than a note that was never done!

      1. umami*

        I appreciate you mentioning this, I keep trying to tell my partner this because he is really good at what he does and is probably overly thorough with his documentation. btu he’s been doing it so long that even when he says he’s only going to spend 20 minutes on a note, that rarely ends up being the case!

    2. Red Reader the Adulting Fairy*

      Medical coding manager here — our providers get warnings and suspensions of privileges if they don’t do their documentation in a timely manner, but in LW’s case it sounds like that hurts them and their patients more than Grover.

      My question is, since you can’t bill until Grover finishes their documentation, how much billable revenue are you losing out on due to timely filing limits? Can you put some penalty on Grover for that — “Because your documentation on these five visits wasn’t completed timely, we were unable to bill them at all which cost us $x-ty gazillion dollars in lost revenue.”

  15. NeutralJanet*

    You can’t legally withhold part of Grover’s salary due to them not getting all their work done, but you can (probably) lower their salary going forward–depending on where you are, you might have to give them a notice period, but assuming there’s no contract, you can do it, as long as the decrease doesn’t bring their salary below the minimum wage (or the exempt threshold, if they’re exempt). It’s usually not a great idea for morale to lower someone’s salary due to performance issues, but if Grover knows that the only reason that they weren’t fired after the PIP is because hiring is so difficult, I’d imagine morale isn’t great anyway.

    1. BKB*

      You can also lower the base salary and then have a bonus that is contingent on completing documentation in a timely manner. My husband works in healthcare and this is how his group handles this issue across the board.

      1. GrooveBat*

        oooh, I just suggested something similar below! Agree this would be a good way to handle this if OP can swing it.

      2. NeutralJanet*

        I had a paragraph initially proposing that as a solution, but honestly, I don’t know enough about payroll to be certain that it wouldn’t be overly difficult to the point of probably not being worth it, particularly if it is just for one person! Glad to hear my thoughts were on track.

    2. GrooveBat*

      I was thinking of a different system, whereby Grover receives a lower base salary but then gets bonused based on task completion. So if there is an expectation that they will complete X number of tasks in a given week/month/quarter or whatever, is it possible to structure the bonus contingent on those tasks being completed?

      I used to work in a consulting company and our comp was utilization based. We received our salary but our bonuses were contingent on completing a set number of projects every quarter. Our bonus scaled up based on percentage completed, so, for example, we would get 80 percent of our bonus if we completed 80 percent of our projects, etc. Anything below that, no bonus. Wondering if something like that could work for Grover? If their work is 100% centered on completing those notes, perhaps you could structure the bonus around timeliness, rather than quantity, e.g., they get a base salary and then the bonus payout based on deadline compliance?

      1. kittybutton*

        This is exactly what I was coming here to say! It sounds like OP believes that Grover will be motivated financially and that external motivation can drive them (based on comment about vacation and potentially withholding pay). If that is the case then Grover may be very motivated by a bonus.

  16. hexie*

    As a fellow ADHDer, I really like the micromanagement suggestion. Know that Grover may potentially really chafe about it at first (I hate being micromanaged! I can be independent! I love flexibility! But I also have my ADHD well enough under control that I don’t miss major important deadlines and if I’m worried I’m going to, I have supports to help get me back on track) but saying “you need to do x notes a day (pick a number that is reasonable and not overwhelming, depending on how long the notes take and how much time they have to complete them) and check in with me on every single one (whether it’s with a “done” email/message, a shared doc where they could make a note in a column, it has to be something TANGIBLE), and then once or twice a week I will phone you to ensure you are still on track”. People with ADHD thrive in routine and structure, and often because dopamine doesn’t inspire us to complete tasks, anxiety and stress about a boss checking in and firm HARD deadlines will.

    I want to also say, you withholding vacation in July? That is not a good ‘threat’ for Grover. It is too far away in the future to mean anything, ADHD is a disorder of ‘the only thing that exists is TODAY’. We also tend to do better with rewards based management – it sounds juvenile, but a system akin to gold star stickers wherein enough gets them something positive (a free latte or whatever) NOW will work better than some nebulous ‘so far away it doesnt matter’ date in the future. That’s why the PIP worked: it was immediate, it was happening NOW, and its consequences are swift and tangible. Losing a vacation in July? You might as well tell them that they’re going to go to hell when they die. It literally doesn’t register as something happening in their world. Future me does not exist.

    I also want to reiterate: Grover isn’t not doing this work because they don’t care or are lazy or whatever. They likely have crippling anxiety and guilt that is eating away at them every single day. They likely go to bed every night tossing and turning and stressed and saying “I PROMISE I will be better and get this done tomorrow” (see me, when I at one point had 1300 unread emails I NEEDED to respond to!). But when the time comes to do it, their brain simply WILL NOT let them start the task. This is so hard to explain to neurotypical people, but it is such a profound mental block almost nothing can break it when it gets entrenched. Grover may simply have resigned themselves to being fired because they are SURE they can’t solve this. But you saying “we can fix this together and it is by doing x y z, and I WILL be checking in and following up constantly” will help them break through the barrier. You will then need to, together, build out some processes to make sure it doesn’t happen again. But I promise you, Grover probably feels worse about this than anyone else ever could. And I believe that they have the capability of being a better employee if you can help create some systems to hold them accountable in a way that will actually work for them.

    1. Tau*

      Also ADHD and that vacation threat would absolutely not work for me. Both for that reason and for the fact that… the things I actually struggle hardest to complete are the ones where there is a negative consequence only to me, and so the threat of such a thing will *not* affect the likelihood of me doing it at all. It’s one of the signs that this isn’t laziness but a disability, because if I were making a choice I sure as hell would not be prioritising tasks this way. (And would also be significantly less sleep-deprived and dehydrated.) Helping them build structure, OTOH, has real potential for all the reasons you mention, and is typically the way I try to hack my own blocks.

      I admit I feel very much for Grover. There but for the grace of god…

    2. sookie st james*

      I also have both ADHD and anxiety and my brain definitely only thinks in ‘now’ and ‘not now’. Our diagnoses explain behaviour but don’t excuse it (at least not always). I respect OP’s willingness to help Grover figure out a way to make this job work for them, because a lot of people have a “I don’t understand why it’s so hard, just DO it” mentality that can be really discouraging.

      My biggest recommendation would be for you to frame this to Grover as a Big Reset. Neurodivergent burnout is complicated and once it sets in it can be really, really hard to escape from. Like scrambling to get out of a sinkhole opening up all around you and just sinking deeper and deeper. So if they feel like they’re on a constant, never-ending improvement plan (even without formally being on a PIP) it’s going to be really hard for them to leave their failure mentality and start implementing the changes you need to see.

      [With the caveat that I have no healthcare experience and that these won’t work for all ND people, here’s some things that would work for me, as my brain responds really well to new environments and change].

      Tell them you’re shaking things up around the office and you want to work with them to rethink the way you work. This is a positive opportunity for both of you to have easier, happier working lives – again, we often respond really well to new stimuli so this can’t feel like more of the same discipline attempts. They would then ideally have a few days off (a weekend at least) to rest and reset their mentality about work before the new strategies kick in.

      On Monday/after the timeout, present suggestions for the workflow changes and work with them to develop a specific, detailed plan that they think will work – but be firm that they have to pick specific goals and tactics to implement, they don’t get to just vaguely promise to do better, as that’s clearly not working.

      Others have suggested great ideas, but a round-up that I would suggest:

      1) Daily deadlines for a number of notes

      2) Specific time slots each day for doing the notes (could be different each day to keep it fresh, but it’s always pre-scheduled)

      3) Using a different workspace write up their notes (a change of scenery can work wonders for concentration and motivation). If there are a few different locations available to keep it fresh, then great.

      4) You have Grover and the other doctor/s do their notes in the same room at the same time (this is a technique known as body-doubling). If this would be a hardship to the other docs or not practical, could they sit with front desk/admin staff, or with you? Talking and collaboration are irrelevant, only the accountability of a perceived audience.

      5) Regular meetings acting as both a check-in on their progress and a mini-deadline (e.g. they have to bring proof of X amount of work to the weekly meeting).

      6) As hexie mentioned, have some kind of system where they can manually check off each completed note/batch of notes (either some kind of to-do list or online programme like Monday or Asana where they mark each task as ‘not started’ ‘working on it’ and ‘done’. Even better if this is an office-wide platform for implied accountability to the rest of the team.

      7) Recognise good work and progress. Not with actual rewards (unless warranted), but verbal praise can be a positive reinforcement.

      8) Random check-ins, announced a short time in advance. For example, send an email saying ‘I’ll drop by in 30 mins, please have [X number of ] / [all of patients Z’s] notes ready by then’ (adjust for reasonable timeframes/goals for the work you do) – a lot of us with ADHD are really – and I mean REALLY good at working under short-term pressure – what would take the average person a couple of hours, we can bash out in 30 mins, but only if our brains decide to ‘click on’. We can’t control it, but unexpected short-term “deadlines” like this can trigger that ‘brain switch’.

      Please excuse how long this is! Hope it helps.

      1. SwingingAxeWolfie*

        This list of suggestions is great. I’d also add – not sure if this has been brought up – but if Grover isn’t allowed to listen to have headphones in while taking notes, consider changing that. When I was in the office (fully remote now), I used to think listening to music was just good for drowning out the noise of the open plan environment. Turns out, it’s actually invaluable for getting through monotonous work.

        Remember also – what works well for ADHD one day won’t necessarily work well the next day, but it doesn’t mean that method is a lost cause for future reference.

        Appreciate it’s not Grover writing in for advice, but as OP seems willing to work with Grover as much as possible, hopefully it’s transferable! Good luck, would be so awesome to see an update to this one.

    3. Ellis Bell*

      Cosigning to the vacation threat point. It won’t matter because it isn’t a real thing to Grover yet. Not as real as all the immediate stuff he’s juggling.

    4. Thegreatprevaricator*

      This this this. It’s horrible. Being in the hole is the worst place to be from an ADHD point of view. I would definitely ask Grover and consider reasonable accommodations as it’s a disability and is affecting their ability to deliver role. Does Grover need to type the notes for example? Can they voice note or dictate? Is there any admin support? In the UK some people have been able to get support from an ADHD coach through access to work which would fulfil a similar role.

      I am able to be pretty upfront with my employer and they are clear about what can/ can’t accommodate but I’m also supported to think about how I can manage and prioritise workload by line manager.

      Study rooms can also be a help – shared ‘office hours’ for admin tasks where it may be just literally be dialling in to a meeting and being ‘present’ for a scheduled time.

      I also find time blocking to be helpful.

  17. Tea and Cake*

    Can you investigate other ways to complete the notes? Dictation, speech to text tools, part time data entry to get and keep Grover caught up on notes?

  18. I'm Just Here For The Cats!*

    Completing notes seems to be a clinician’s nightmare sometimes and everyone always gets lost in a pile of notes. We’ve had problems in the past (but not to this extreme) with clinicians not completing notes or having 20+ notes to complete at the end of a week.

    One thing I would suggest is to see if there is enough time in the day for him to complete his notes without having to stay late or work at home. It could be that he doesn’t have time between his sessions to do the work. Then is tired after seeing patients all day and so the notes pile up. If at all possible could you build time within his schedule that is dedicated to notes? Like in the morning and then again at the end of the day and maybe sometime in between if needed? And make it clear that these times are not to be used for other tasks or for patience. Also, make it clear to schedulers that those times are not for anything else. And if at all possible make it so he cannot be disturbed during those note times.

    Another thought is there any way to streamline the notes? Is there a template or anything that could be used so they are not starting from scratch? OR could some of the notes (or all?) be done while they are with the patient?

    I’m not sure if you’ve asked him but have you asked Grover what he struggles with for completing the notes? That might give some clues on how to best help them.

    1. I'm Just Here For The Cats!*

      I also realized that I occasionally referred to Grover as he/him instead of they/them. Sorry about that.

    2. Sloanicota*

      I also wondered if there was anything Grover thought might be done to streamline the notes to make them more palatable. Color coding, autofill, anything like that might be easier than hiring another person to replace Grover.

  19. M. from P.*

    As a clinician myself – would it be feasible to get Grover some kind of clerical support? Could they dictate their notes in real time? Are there any technical issues with the note taking system that make dealing with it an ordeal? Have they ever raised any concerns about the user interface that haven’t been dealt with? I would really dig into why the documentaction causes them such anxiety. It may be that there’s no real reason but maybe there is some actual difficulty /annoyance that makes not dealing with it in the moment easier than writing the note then and there.

  20. OP*

    Wow – having Alison answer a question feels like being internet famous! Alison, I really appreciate the empathy re: the situation and your concrete advice re: increasing management. I can answer some questions that are already popping up (the comment section here is so great that I’m looking forward to feedback here, too!):

    –The caseload is unmanageable. My own is unmanageable, so I probably shouldn’t even be taking time to comment (lol). That said, Grover is not overbooked. It just means we don’t see people as frequently as they need to be seen (which loops back around to why I haven’t pursued termination without a replacement). So I actually see more people/day than they do consistently, and don’t have a problem with the documentation except in cases where it’s typical for healthcare (e.g., an acute crisis that requires follow-up care and extra documentation).

    –Grover does have time between visits for documentation. They just don’t do it, or don’t do it consistently. Which is anxiety/avoidance/poor time management, all of which we have discussed how to address, with clearly limited success (although 50 is better than 300!). Concurrent documentation would also be fine in our setting, and our electronic medical record is (blessedly) not super cumbersome.

    –Umami, you’re spot on re: anxiety about the content of notes themselves. This has been another major focus, with some success. The weird thing is that Grover’s notes are fine when written! Which I tell them all the time! They have made some noises recently about therapy to address this issue, which I have obviously been very encouraging regarding, and even provided several names of people with openings.

    –Really loved Alison’s suggestion to ask Grover what they would do in my position. I have done a version of this, and Grover said they would fire themself, but it was partially joking, and I’d love a more serious answer. Grover is as aware, if not more, than I am, about the underserved part of the job, so I’d be curious to see what they would say about balancing serious performance issues with meeting community need.

    (Also, I thought about emailing Alison about this for a while before doing it – if you’re on the fence, just do it!)

    1. Healthcare Manager*

      I’m an ex-mental health clinician and I remember the days of note writing.

      If Grover has anxiety about capturing the content can you implement a safety net, ie you will check and let them know if any notes need more information/clarification.

      You set this up at a frequency that makes sense for YOU, you be clear that as management the responsibility is on your head not theirs. You don’t even need to tell them how many of their notes you’re going to check (cuz otherwise that’ll start anxiety about how many you’re doing), and in fact you’ll probably find that you won’t even need to check at all.

      Part of it is about creating a safe space and team comradely about the record keeping.

      1. OP*

        Thank you for saying this – I review some notes every week, and make sure to *always* give positive feedback, and Grover is aware (and makes use of) me for proofreading for trickier documentation situations. That said, this is worth revisiting. I can get feedback from them about how frequently I’m doing that, if there are any barriers to asking me to proof, etc.

        1. Healthcare Manager*

          Just to be clear, I said DONT tell them how frequently you’re checking. You want to create a safe place so they know there’s a safety net – that does not mean you constantly check or report back! By reporting back you’re enabling the anxiety cycle (they’re just waiting for your positive feedback).

          1. OP*

            Appreciate the clarification. They already know I do it weekly, but not more specific than that (I do it twice – once when just reading notes from the previous week in a sort of “at random” way to get a good sampling, then again when I run the report). I do need to read that often to make sure I have positive feedback to offer, too, and I think what I meant was checking in with Grover about whether the current feedback feels reassuring or anxiety-provoking. I will see!

            1. Healthcare Manager*

              I think you’ve gotten yourself in a bit of a pickle where you’re stuck reviewing notes because Grover expects it. It’s unrealistic with workloads for you to be doing this particularly as you’ve stated there aren’t any issues with their notes.

              I wouldn’t be giving any positive feedback at all – it sounds like you’re doing this to try and convince them their anxiety on note quality is unfounded, which isn’t how it works!

              Instead, just an occasional reminder you’re checking and you’ll let them know if any issues. This gives you autonomy over frequency and removes their anxiety about waiting for feedback (positive or otherwise) because they know you’ll tell them if issues.

              Then after some time you’ll decrease how much you’re checking (again, not telling them). Eventually you’ll rarely be checking at all. But importantly they need to still have the sense of the responsibility is on you.

              Empowering not enabling is the goal here.

              1. OP*

                Oooooh, this is so helpful for me – I was reviewing notes in part of my overall check with the backlog, but I totally hear what you’re saying about how that might be landing. I don’t get the impression that Grover is waiting for feedback, but can’t rule it out. One thing the comments are really driving home for me is that there is some difference between how I approach this if I think Grover can get a handle on it (which would entail moving in the direction of autonomy, even in baby steps) versus if this is something I need to accept isn’t going to change (when options like scribing or reconsidering termination are more salient).

                1. Healthcare Manager*

                  Good to hear!

                  It’s also a good idea to focus on what’s your remit, and your problem to solve, and what’s firmly in their basket of responsibility.

                  You obviously care which is lovely and it can get very blurred when you’re in this situation and want to solve the problem.

                  Good luck! Come back and update us!

    2. umami*

      Yeah, I bet the ADHD part really inhibits their ability to concentrate and *just get it done* right after seeing a patient. It seems so obvious, but I’ve seen my spouse struggle with that, too. If it’s a routine visit, he will do it, but with more complicated visits (like a start of care or recert) there’s just so much that needs to be done, and one note will take him hours to complete because he also is a bit obsessive about his documentation. He’s starting to put time limits on it, but I think that actually makes him feel a bit more anxious, and me complaining that he’s taking too much time and spending all night in his office makes him even more anxious and is counterproductive to what I want, too, so I understand the struggle!

      1. Anon the Fed*

        This is the exact reason why I suspect I have at least a touch of undiagnosed ADHD – I was prescribed a really light dose of meds for anxiety, and now I CRUSH my to-do list at work. I was a terrible procrastinator before this (still am personally sometimes, but less so especially at work) and had to fight that ‘let’s just let this sit’ tendency for any work that wasn’t urgent to give to someone else, or that (in my mind) was particularly onerous to start. The closer a self-imposed deadline would get, the more anxious I’d be. And I never noticed it until I was medicated. In that way, I kind of feel for Grover. But also, seeing the impact my lateness and procrastination had on other people in this obvious way would really have pushed me to therapy sooner (if it’d been the case at my job, which it wasn’t).

    3. I'm Just Here For The Cats!*

      Thank you so much for the info OP! I’m wondering if Grover would find a scribe to be helpful. Would there be any way you could set it up so that they record their notes and then someone could transcribe them into a note? Then all Grover would need to do is read it and sign off.

      And transcription can be done remotely so you wouldn’t have the same concerns about hiring someone in a rural area.

    4. Momma Bear*

      There are a couple of websites/magazines that have information on ADHD and how it can impact adults. I mention them because you said Grover believes they have this/anxiety. Maybe looking through ADDitude and you will find some targeted information for managing an employee with this kind of pattern. Things that can help folks with ADHD include chunking, deadlines, and doing work in the presence of another person. Can they, for example, do their notes in the office with another coworker/you nearby? If Grover agonizes over the contents of the notes, can you point to good ones they wrote so they have a template to follow? Can Grover use talk to text or a voice recorder in the moments after the visit/during the visit and transcribe them later? That kind of thing. I’m assuming that notes are only something the in-person provider can do? Or can you hire an intern to transcribe and Grover reviews? Again, not ideal, but spitballing here.

      None of which is an excuse to not do the work required, but my suspicion is that Grover is trying but struggling. One of the fun aspects of having something like ADHD is the thing you need to do to get diagnosed and treated is hard to do – forgetting, task initiation problems, anxiety…so while it may seem like Grover pays you no mind about getting therapy, it’s probably a task initiation problem more than a desire to do better problem. Do you have an EAP? Would it help?

    5. OP*

      Fellow commenters! I just appreciate you so much :) More details (I had a no-show):

      –Dictation is an option. I had mentioned this a while ago to them, but will again. It doesn’t really address the anxiety part of the equation, but I’m willing to try anything.

      –Scribes wouldn’t work for our setting, but I love that suggestion for others!

      –The current plan is that Grover completes all notes the same day. They are doing better with that than with their backlog, but one thing Alison’s response really made me realize is that there are limits to how much time I want to devote to monitoring the backlog. I check the backlog at least twice/week, but not more than that, and will have to put some thought into what increased monitoring I’m willing to do, and at the expense of what else.

      –Grover does have access to templates, including an easy way to copy/past from previous notes with a patient.

      –Really appreciate the folks mentioning things like the Pomodoro technique – haven’t mentioned that specifically, but I will!

      –@hexie, I loved your last paragraph. For a variety of professional & personal reasons, I’m well aware that this is mental health, not a lack of caring, and Grover knows that’s how I view it. They have given me feedback that I’m approaching the issue compassionately with them. I just want to be compassionate AND effective, and I want better for them, too! I can’t imagine how much anxiety a backlog like that would cause for me, especially if I already had anxiety about documentation. I really appreciate you naming the emotional dynamics explicitly, though, for anyone reading who might not be making that connection.

      1. JSPA*

        How sure are you that remote medical scribing would not work (if for example you could get A satellite phone link for video?).

        I have a friend who has some Grover tendencies, and pays for remote scribing out of their own pocket! I suppose you can’t ask for grover to play for scribing out of pocket… But then again if you offered to (say) reimburse grover for half the cost and supply the reliable video link…are you 100% sure it’s a nonstarter?

        1. I'm Just Here For The Cats!*

          I’m thinking OP means that for the type of work they do scribes won’t work. Not that its a rural area. Lets take the OP’s word that they know what will and will not work and that scribes won’t work

          1. JSPA*

            There are several reasons that people believe the service will not be possible, and my friend has worked through multiple of them.

            No money to cover direct payment or additional hiring
            Outsourcing not allowed (if paid by the company)
            Prohibitive certification requirements if hired directly

            They literally say it’s a very remote rural area, to the point that it makes recruiting difficult.

            I’ve lived in a merely semi rural area where recruiting was no problem, But (until 5 years ago) video quality cell service (or adequate private internet) was only possible in a tiny strip of the commercial district near the university.

            Sure, this could also be a language issue, depending on the unique population served.

            Or combination language / privacy issue, If practically every speaker of (say) a small indiginous language is related to every other speaker.

            Or any of the other issues (several of which I touch on). But my main point is the place is hiring my friend were almost universally certain that remote scribing was not a possibility for them…until my friend found the worker around that worked for them.

            1. AnonymousMentalHealthProvider*

              I’m assuming it’s mental health treatment, where a scribe is not a possibility for a few reasons, not least that patient notes are inherently a balance of objective and subjective, and they are neither a transcript nor narrated impressions during an exam.
              I’m thinking of my orthopedist who will essentially “think out loud” for the medical assistant/scribe. My therapy patients would be pretty alarmed if I did that during a session! :)

      2. Healthcare Manager*

        Hey OP

        RE telling Grover Pomodoro technique

        You really need to be careful you don’t fall into the trap of solving this problem for Grover. You need to focus on your role as a manager and being supportive and not try and find solutions for how Grover manages their anxiety/ADHD.

        1. OP*

          Fair! This is a tricky line I’m not sure I always walk well between problem-solving the performance issue and getting too involved.

        2. Em*

          Yeah, this right here. Some of these comments are so detailed and extensive in their recommendations that I think people forget that 1. regardless of what they’re dealing with, Grover should be expected to complete their work and find solutions when needed, and OP should play a supporting role in that, not a driving one 2. OP has their own job and probably can’t spend all day with one eye on Grover, double checking work and offering solutions and encouragement at every barrier. It’s not feasible to act as a guidance counselor to your problematic employees, and it’s disempowering to them if they feel that their manager is actually responsible for solving every issue they struggle with. In this dynamic, it would be easy to see Grover believing that finding a solution doesn’t really matter because there’s no hard consequences when the work isn’t completed (other than some uncomfortable conversations). The fact that they’re joking to their boss “I would fire myself” doesn’t give me good vibes about their commitment to solving these issues.
          It sucks that hiring a replacement is such a challenge.

          1. sookie st james*

            completely agree with this. I would have a lot of suggestions if Grover was the one to write in (while being fully aware that most ADHD people, myself included, have been told about the pomodoro technique, to-do lists, etc ad nauseum by neurotypicals and they either don’t work for us or only work for a short time).

            I gave specifics about this in an earlier comment I made but I think it would be worth it for OP to devote a certain amount of time to building in an accountability and support structure for Grover (via scheduling changes, implementing deadlines, and/or changes to the work environment) but after that point, they should expect Grover to figure out how to make it work. Their ADHD explains their behaviour but doesn’t provide a perpetual excuse for not doing an essential part of their job.

            The goal here should be making OP’s life easier in the long run, without requiring constant hand-holding for the rest of Grover’s employment there.

      3. bamcheeks*

        How clear is your template for note taking? I struggle with notes after appointments in my role, and having a basic template that’s like:

        Sentence summarising presenting issue

        Three bullet points summarising discussion

        Two sentences summarising next steps

        makes it SO much easier. It takes it from a “oh god I have to think of all these THINGS” task to a “I just have to fill in these blanks!” task. It almost turns it into a puzzle, which is 1000x more rewarding for my brain.

        1. Name goes here*

          Okay that type of template for a repetitive task such as a memo, status update, what-have-you is a game changer for me. Thanks you!

      4. AnonymousMentalHealthProvider*

        OP, you have received so much crowd-based wisdom here! Sorry if I missed it, but would you be willing to show Grover this question and thread? I can imagine this could be overwhelming, but it could also be a great way to return the problem solving work to them.

        On the practical side of things, you mentioned that Grover does have access to templates. I have found some varieties of them more beneficial than others, but having a right-in-front-of-me reminder of what needs to be included is often helpful.

        Over the years I have veered from too extensive notes to “okay, that was too brief.” (My poor internship supervisor!) I’m assuming that Grover is aware of SOAP or similar for a basic structure. I appreciate having such a bare bones outline as a reminder that a complete note doesn’t have to be a work of art!

        And ultimately, a *done* note is the goal. The done note will always be better than a nonexistent but perfect note.

      5. Boof*

        I see you say scribes aren’t an option, and in general I’m all for taking folks at their word, but frankly a scribe or something extremely similar (someone to sit down/do notes with Grover regularly) really sounds like the only long term options other than firing Grover or being on a permanent cycle of policing them. I say this as a doc who struggles with notes (but am certainly not that behind) – if care providers are the shortage then there should be some way of finding support to shore up specific weaknessess if the doc is otherwise good / you want to keep them. If grover has struggled this hard and back slid this much already after improving it’s not a problem that’s going to go away if the conditions are the same.

      6. Ellie*

        I don’t suppose you could offer any kind of incentive? Get x amount of documentation done and you can leave early, or documentation all complete by Friday and we get donuts, or anything like that? Yoga classes maybe?

    6. raktajino*

      >> “The weird thing is that Grover’s notes are fine when written!”
      I used to have meltdowns in elementary school before spelling tests…and then ace them. My grad school thesis was defined by the crying anxiety attacks every time I sat down to work on it. Academic anxiety is such a real thing with ADHD, and I’m so encouraged that you’re trying to approach this with empathy and kindness alongside practicality.

      The backlog sounds incredibly intimidating. I assume you’ve already tried to break the issue into two different parts: the backlog and the plan going forward? I realize the backlog needs to get done for insurance and continuity of care. But for me it’s less intimidating to think about keeping on top of things “from now on” than to think about catching up. I think the two problems have different solutions. Going forward, implement new strategies. Backlog, come up with very short term deadlines (10 by Wednesday, 5 more by Friday) and experiment with strategies to make that happen.

      I second everyone’s suggestions for dictation software and scribes. Another thing to consider: a less formal dictating scenario? Dictating can be intimidating because it’s so permanent and precise (even if you’re revising). Is there room for at least some of the notes to be a conversation between them and another professional? Grover can loosely tell a colleague how the appointment went, the colleague can ask clarifying questions, and it feels more like a conversation. That way, they’re not feeling pressed to remember *everything* or phrase something *just right*.

      I’m not a health care professional so I don’t know what health care notes look like on the back end. Do they have really specific prompts?

      Again, I really appreciate the empathy you’re approaching this with, and hope you find a solution.

      1. Hapless Bureaucrat*

        Dictation might actually help address the anxiety! I’ve seen it used as a support for students with anxiety around writing papers before with success. It can cut off a little of the perfectionism.

    7. Also ADHD*

      So I know this may not be an option, but is there a way to make things a little less open ended? So, for example, having to check a few boxes instead of it being all free text.

      Another option could be to have some short questions to answer. So like, name:
      Reason for visit:
      Etc. sometimes having to write out everything freehand is really daunting, and this is a way to sort of break it down into some smaller sections. Also if he can at least get a few things down like this even if he doesn’t fill out the entire note he’ll have something, as well as something to reference when he gets back to it.

      It’s almost like an artificial way to employ the method of breaking a big task into separate smaller tasks to get it done. My guess is the more you can standardize it too, the easier it will be.

    8. GeorgeFayne*

      As someone who handles monitoring this kind of stuff in a medical practice – I TOTALLY understand where you are coming from.

      In your EMR system, is there any way to set up templates/general formats for note purposes? Or even a drop down list/menu selection with some commonly used notes (if every patient presenting with specific criteria all end up with similar documentation, a jumping-off point/boilerplate could be saved and then used to help start the documentation)?

      Our practice involves some Ancillary Service Providers who see a very small amount of high complexity patients each day. They all have their own ways of handling the documentation, but like what you are describing here, a lot of times it’s a matter of “I don’t even know where to START with this one”. So we have found that having an outline or some pieces of documentation that can be pulled in and then edited to fit the current patient is very helpful (as long as things are being edited for the specific patient and all of the notes are not just let with only the boilerplate … but I’m not going to start down that road).

      I would like to echo Allison’s idea to start with a certain quota for each day (finish all of your notes and do five of the backlog notes each day, or something along those lines) to maybe make it feel more manageable and not such a huge insurmountable chunk. We run this information for all of our providers on a weekly basis, with a big push at the end of the month – and since the providers know that the reports will be run on a certain day each week it kind of gives them a soft deadline if they don’t want to be sent a list of their backlog. For our more problem providers, we used a daily quota to help get their backlog taken care of and now they can be maintained with the weekly checks/reminders.

      Best of luck!

      1. OP*

        Really appreciate everything you said! There is already a basic template that’s adequate for my needs, but I don’t have anxiety about this. You’ve got me thinking a productive way about a more structured template that I would potentially find constrictive, but maybe Grover would find freeing! Follow-up question about the quota for each day – Grover will set up a plan for this, but then not follow through, in part because they will acknowledge that it immediately evokes anxiety about whether they will be able to follow through on it (Humans! So good at getting in our own way!). In your practice, what happened to a day’s quota if it wasn’t met? Did it just get added to the next day’s quota?

        1. GeorgeFayne*

          Thankfully (for me) I wasn’t in charge of enforcing the quota – just running the information to give to the person enforcing it. :o)

          If I remember correctly, when the quota wasn’t met it was tacked on to the next day … and then at that point it was a “You are coming to my space to complete these while I am also in the office” kind of deal. Which – with ADHD and the idea of “body doubling”, it can sometimes be easier for a person to focus and complete a task when someone is in the room with them (as long as there are no other fun distractions). The person in charge of enforcing didn’t let it get past a day or two (which unfortunately meant staying very on top of checking what had been done). We used a spreadsheet system to track the progress (I had the original backlog list pulled from our EMR and daily I would pull that report again and quickly check to see what was no longer on it). We also have the ability in our EMR system to pull the date that a note was locked, to check the number of days that it took to lock the note and also to count the number of notes locked by date. That was very helpful to us to see if the quota had been met or not.

          I understand that it’s difficult when you feel like you don’t have power to enforce the behavior you need to see. The biggest help I have been able to find (since my job is telling people they need to do things correctly with ZERO power to enforce it myself) is getting the providers buy-in on what we need to do. We’re going to create a standardized template for this specific visit type and we need to include X, Y, and Z – what order do you think it should go in, and what are some pre-built options you think we should include? Similar to dealing with children – you have to put on your coat and gloves and boots – which one do you want to put on first? We’re doing it all, but you can decide how you want it formatted.

          And yes, some providers like a VERY restrictive template/documentation format. It reduces the amount of imaginative thinking they need to do when crafting their notes and they can just fill in the information where it is needed … while others need to feel their freedom. This is why we have a section of our notes where documentation can be “saved” essentially and pulled into a later note – each of our providers can have their own specific notes they know they want to use for future patients, or if there is a consensus we can add in notes that can be universally utilized.

          1. OP*

            This is all so helpful! Thank you for taking the time to reply with additional info.

            1. GeorgeFayne*

              One final thought – if you have “buckets” or places in the EMR system where these backlog notes sit, maybe create a “Daily Quota” or appropriately named “bucket”/folder/name to assign to so that Grover is not overwhelmed with a huge list when they go in to complete the notes. Drop 5 to 10 notes in at a time and it is easier for Grover to navigate as well as for you to keep track of. :o) Best of luck again! I’ll be watching out for an update.

        2. theletter*

          Maybe it’s the process of writing out sentences that are so damning? Grover might be struggling with crafting essays, but a short list of set phrases that cover most circumstances would allow Grover to select and save. They could flag things for follow up and then return at the end of the day if they want to write more comprehensive notes.

        3. Jaydee*

          Speaking from experience, Grover probably needs to try setting a plan/goal that is 100% attainable. It will feel so basic and simple that they will feel ridiculous about it at first. But as an ADHDer with strong perfectionist tendencies and no concept of time or my own energy levels, I would set goals like “will clear 50 note backlog by Friday.” On Wednesday. But if each note takes 20 minutes to write, that will take ~17 hours over the course of two days in addition to my regularly scheduled work, and that is unrealistic.

          So Grover needs a ridiculously simple goal like “will finish current notes each day and complete one backlog note per day until backlog is cleared.”

          Grover will resist. They’ll say “Oh, that’s silly! I can do more notes than that each day! They need to be done ASAP! They can’t wait for 50 days!”

          But the truth of the matter is that Grover *can’t* consistently do more notes than that each day. They can’t even consistently complete their daily notes every day. They need to start at the bare minimum.

          After a few days of meeting that artificially small goal, they’ll feel a little more confident. “Hey, I’ve kept up with all my current notes and done one backlog note each day. Maybe I’ll try doing two or three a day….” And then they’ll have a day when they get hyper focused and finish half a dozen backlog notes in one evening. Not because they gritted their teeth and white-knuckled through the anxiety, but because they just got in a zone.

          It will probably not take 50 days to get the backlog caught up. It might take a couple weeks. But the more important part is that Grover will have built a habit of keeping up with their current notes every day and will have a system in place to realistically address future backlogs if/when they occur.

          So instead of 300+ backlog notes or 50+ backlog notes, they can say “Oh crap, I didn’t finish my notes yesterday and have 4 extra to do. Well, I’ll do two today and two tomorrow and then I’ll be caught up.” Rather than “Oh crap, I didn’t finish my notes yesterday. Here we go again! I thought I was doing so well, but I just can’t keep it up.” and then feeling anxious and down and not finishing today’s notes either and then the backlog grows.

    9. Nightengale*

      Oh I am a Grover. Neurodivergent physician (in a field that is more like mental health than like other branches of medicine) who is chronically behind on charts.

      We are overworked in my practice and while not having notes completed is a problem, there are often more time pressing urgent problems of patients in mental health crises, medication issues, letters that need to be written for schools. . .

      Definitely time right after the visit is not helpful for completing charts for my neurodivergent brain. Brain is still on last patient or knows that the next patient is here or has 3 forms that need to be signed Right Now. Nor can I write sentences that will be usable in a note while the patient is actually there in front of me during the visit.
      And sometimes Brain just need time to Word, especially for new patients. Note writing is not creating writing in the fiction sense but it does involve word finding. In my field, people often share my intake reports with other providers so the wording really matters.

      The things which have been (somewhat) helpful for me – dedicated larger blocks of time at home to write notes without external interruptions and making my own templates in our EHR.

      1. umami*

        Another problem I’ve seen for my partner is having to do communication notes BEFORE he can start on the actual documentation note. If we have plans in the evening, that is the one thing he has to do before we even leave, because that part can’t wait. Which also contributes to him starting off behind on the actual notes.

      2. Data Bear*

        Yeah, it sounds like “do notes right after seeing the patient” may be a significant part of the problem. I find task-switching VERY draining, and it’s nigh-impossible if you know you’re just going to have to switch back in 15 minutes.

        OP, can you arrange things so that Grover does notes all in a chunk at the end of the day?

        1. Good Enough For Government Work*

          Thirding this. I can get SO much work done, but only so long as it’s one task at a time.

    10. Frog*

      seconding the suggestion for a remote scribe and/or speech to text software that allows him to speak the words, then edit any mistakes. it may not fix the problem, but it’s an idea

    11. Former Scribe*

      Not sure if this is feasible, but is it within budget to get a scribe? I (medicated ADHD) worked as a scribe with a PA who was in her 60s and knew that she had a pretty bad case of ADHD, but hadn’t gotten it diagnosed. Similar situation- very good care, often lots of backlog, great patient communicator, but she needed an external crutch for the organizing portion (myself and other scribes- she wasn’t the only provider we worked with as well). So there was somebody there who was consistently doing the majority of the documentation, and while she would get a bit behind on signing off, on slow nights she would sit down and we’d just run though all the notes she had yet to review and sign off on.

      1. OP*

        Enough people have suggested a scribe now that I need to look into it more. Thankfully I’m not in an org with incredibly tight finances, and I would certainly have support from higher-ups to at least consider it. I’m curious what Grover would say: I can imagine either relief, or increased anxiety about having a “witness.”

        1. ThatGirl*

          It is hilarious to me how many “Scribe!” comments I just scrolled past.

        2. Healthcare Manager*

          You can get scribes that write up proper notes from scribbles. They don’t need to actually witness the session.

        3. Marna Nightingale*

          As someone with a similar brain to Grover’s, I think you can probably at least tilt the odds towards “relief” quite a lot with a script that says, in whatever way works best for you, “this is not a punishment, this is an accommodation, we’ve seen you try really hard on this and do a really good job with what you are able to do but it’s not working AND it’s eating too much of your time and energy and we want you to spend less time fretting about the one thing you struggle with and more time thinking about the stuff you’re great at.”

          Which is true. I know how serious a problem documentation is, but I also can see, putting myself in Grover’s shoes, that they probably spend a LOT of time worrying about this, feeling bad about this, feeling scared about this, being mad at themselves about this… none of which is helpful but all of which is exhausting.

          If Grover is a good clinician now, a scribe could free up enough of their mental real estate to let them be a great one.

          It’s not that not doing documentation isn’t a problem. It’s a serious problem. But it’s way more fixable than “poor or callous clinical care, great paperwork.”

          Which is a thing you’re obviously aware of, but maybe say that to Grover explicitly: we’re working with you on this because we want you, specifically, caring for clients, enough that it’s worth it to us to make this work.

          From experience, that can be enough to break through the shame cycle of feeling like this is yet another time we fail because of “one stupid easy little thing that everyone else can do that our stupid little brains refuse to grit up and cope with”, as my brain but not I myself would put it.

        4. NonProfitED*

          Before my doctor retired she as a scribe who had graduated medical school and was waiting to get into a residency program because she was from Spain. She worked for her for a year but since she had completed medical school it was really easy for her to be a good scribe for my doctor. My doctor did not have ADHD but she felt having a scribe allowed her to focus on the patient and kept here records up to date so all she had to do was review them at the end of the day to make sure everything was correct. If you have a great Medical Assistant maybe they could be assigned to this provider to be a scribe as well.

    12. Also ADHD and anxious*

      So one thing with ADHD is that we don’t have a great sense of how time works. Is it possible that Grover stresses out about appointments running over time/not being able to get their notes done before the next client comes in? That could be paralyzing. There’s something called “waiting mode” where if you know you have an appointment and can’t figure out how much you can actually get done before your appointment, you end up doing nothing. It’s honestly super frustrating and stressful. Would it be possible to group all of Grover’s note-taking time together into a single block, so their appointments all happen one after the other and they take notes at the end of the day?

      The concept of “body doubling” might also help – just having someone sit in the same room and work on a task of their own while Grover works on their notes could be motivating but not stressful, especially if it’s someone Grover can turn to and say “hey, how would you phrase this?” when they’re feeling anxious about the quality of their notes.

      Also seconding a suggestion above about micromanaging a bit – if Grover’s been able to let this slide without real consequences to other people, their brain no longer thinks of their notes as something urgent that must be done immediately. But urgency is one of the main drivers for ADHD people (basically, if a task isn’t new, interesting, or urgent, it’s hard for us to get it done). But if you can say “hey Grover, I need the notes on today’s clients plus three from your backlog by the end of the day”? Grover will probably get those notes done. We need real deadlines to be able to accomplish things.

      1. umami*

        ‘So one thing with ADHD is that we don’t have a great sense of how time works.’

        This is also a really helpful framing.

      2. Nesprin*

        It’s also worth noting “waiting mode” is a consequence of ADHD time blindness- i.e. not wanting to start something in a downtime because you’re worried about being late to the next thing.

        If I know I have something to do in 15 minutes, if I start something, there’s a decent chance I lose track of time in that 15 min and end up late to the next thing. This has happened enough times that I watch the clock instead of using those 15 min.

        1. I went to school with only 1 Jennifer*

          This is where knitting is really helpful to me. (And I do fairly simple stuff on purpose, because I know how my adhd brain works.) I can pick it up for 5 minutes and get something worthwhile done with that time. …I also use the timer function on my phone all.the.time to remind me of when 10 minutes have gone by.

      3. Ms. Hagrid Frizzle*

        I’m ADHD and I live and die by my timer because waiting mode/time blindness is such a struggle for me. It’s not perfect – depending on where my timer is/what timer I am using and what task I am on I will silence it and then forget I have done so – but it’s most helpful in allowing me to get things done in my waiting mode.

        For example: I truly struggle to wash my dishes, even when I have time to do so before heading to work because what if I don’t get them done/what if I loose track of time and am late leaving the house? But since starting a 10 minute timer on my phone (and placing it on the other side of the kitchen) and telling myself “you will wash dishes until the timer goes off” I have been able to stay on top of my kitchen chores! The phone and location are critical here – because I cannot turn off the phone timer with my voice and have to dry my hands and physically leave the sink to turn it off.

      4. Adultiest Adult*

        The body doubling technique (never knew there was a name for it!) is how I have wrangled some very ADHD people through required work in the past, even though the person doing the ‘supervising’ has to have the patience to do it. First time I ever used it, I was a grad student managing up and got ‘nominated’ to be locked in a room with a staff consultant who couldn’t get an important report completed otherwise. I’ve since successfully used it with colleagues, and as a manager in a very similar context, it is the only way some of my clinicians have ever cleared their backlogs. Good luck, OP, because it does take patience, and it is definitely a trade off, that this person’s work is ultimately valuable enough to justify the time of two staff members to make sure that it is done to a particular standard.

        1. Rapunzel Ryder*

          One word of caution on body doubling, as a fellow ADHD professional, beware of chit chat. If Grover is an extroverted ADHDer, it is very easy to turn a body double into a new distraction. The person with ADHD can rationalize it as a good distraction (I am building relationships with my co-workers, we are talking about work things, they probably think this is weird and awkwardly silent so I need to fill the space, etc), but then later realize what happened and it becomes a bigger problem because now talking at all is another source where they can screw up (I talk too much or too little, they think I am crazy or a jerk, etc.).
          For myself, I have found the mid-way hack since I am lucky enough to have a door with a window to the hall, I am one of few who does not have window treatments. It gives me the shield from chit chat but there is always the potential shame of someone catching me being distracted (which is usually how body doubling works for me). Or if someone has to be in the room, such as sharing the office with a temp, put on headphones or ear plugs that can be seen. As long as you pass on to that person what it means, they can know you are in focus time so not to take it as rude if you do not chat.
          Also as a laugh to myself, it is totally not obvious my Adderall has worn off for the day with all those commas, tangents and ADHD parentheses, rambling, and lack of going back to proofread lol.

    13. cryptid*

      Grover sounds a lot like my fave provider to MA for, and if you weren’t rural I’d wonder if it was them! I liked working with them (incoming ms1 this summer!) because they really put a lot of effort and thought into the care they provide, but it could be deeply frustrating for coworkers and patients because of the unfinished documentation.

      One of the big problems my provider would run into was that because they were thorough and friendly (+ adhd time blindness), they almost always ran over – destroying that protected note time. Is this a problem for Grover? It was partially a patient led problem, too, because people would wait weeks for a visit so they wanted everything done now when we only had 15 minutes – I’m sure you know that feeling! My provider was super sympathetic to it, so it compounded over time as they’d try to do more at each visit, run later and later, not get stuff documented so referrals never made it out, so the next visit was trying to fix all that plus whatever was new. We started being very firm about 1 issue per visit and leaving on time and it helped some (obviously with some flexibility when needed).

      Is it possible to get Grover a scribe? I know that might be a huge budget hit but it may also effectively solve a good chunk of this. I did a lot of informal scribing for my provider (typing up most of the note per their instructions and then they’d put it in the chart), which helped quite a bit to get notes in on time. I was good at my job so I could afford the time to do it, but a dedicated scribe would’ve been better.

      1. cryptid*

        Lol I scrolled down to find a bunch of us think a scribe could help!

        Based on some of your other answers, I wonder if part of it is Grover is getting hung up on the chart being accessible to patients now? I know it changed how a lot of people document, not always in a good way. If that’s the case, a more rigid note template may be part of the right solution – it gives the info needed and only that, with consistent language for everyone.

        1. Daryush*

          Agree with the rigid note template! Your note doesn’t have to be a 5-paragraph essay.

        2. OP*

          Great question, but no re: patient access to records – their anxiety is more like, “If I was subpoenaed to defend my patient care in court, how would I justify my interventions?” I try *really* hard not to overstep my boundaries, and do appreciate Grover’s insight, but obviously that’s fairly catastrophic thinking, not to mention that, ironically, late notes is less defensible than imperfect ones! So that’s another thing I struggle with. I can see clearly based on Grover’s self-report why they’re struggling, but it’s also pretty firmly in “Take that shit to therapy” land. I say that as someone who is in therapy themself!

        3. Boater*

          Adding on to this, and perhaps this is an Eat That Frog thing, but what if you combined a rigid template AND changing the definition of good-enough? Instead of closing the note, Grover has to complete a “shitty first draft” before his next patient. (The shitty first draft trick lets an ADHD brain jump in without worrying about getting it just right.)

          Eight times out of ten a shitty first draft is absolutely good enough for the purpose. And Grover might find that, too. Or Grover might get a good start, use their time better throughout the day, and then find it way easier to close them all out at the end of the day.

            1. Cksjs*

              100% get a scribe! It takes so much pressure off, especially when it comes to remembering things! In this case, I feel like an in person scribe would be ideal, they could do the basic note, then, if you can find the right person, gentle encourage Grover to do the finishing touches and close the note. I have an overseas “virtual” scribe, which is a huge help, but also has some challenges. You can also hire a remote scribe I’m sure anywhere in the country (overseas is cheaper…. Of course). You can pay someone, either in person or remotely, but either way probably like max $20hr (overseas $9hr….) to take this off YOUR plate!

          1. lilyp*

            I was also going to suggest a “shitty first draft” framing for the in-between-patients-time notes! I wonder if that would also reduce the context-switching load, like, they don’t have to get into Writing Mode, they just need to jot a few key phrases about what they’re currently thinking into a text box and save it to “clean up later”

            I also wonder, since everyone has to do notes, if there’s another provider who would be interested in doing a “buddy system” thing? Maybe set up half an hour at the beginning or end of the day for them to sit together and catch up on notes/other admin tasks.

      2. Ursula*

        Yeah, from the sounds of it an in person “scribe” would help a lot, not even actually as a person who is writing the notes, just as a person to push him to do it now, not later.

    14. anon when talking about adhd*

      Does Grover need more time to reset between patients (aside from note-taking)? As a fellow ADHDer, I need more time/energy for context switching than the average person, and it’s REALLY hard to admit that, because of the stereotype that we thrive on “chaos” or whatever. There’s a bunch of things I do that are supposed to be done in parallel a little of each each day that I just schedule in blocks because I will absolutely not succeed at slotting them in around other things. Going from working with a patient to notes to a different patient is two big context switches in short order.

      The usual advice to “just make it a habit” won’t work in that case; they may not realize what’s blocking them, if it’s just that they need that space in between patients to [white noise hissing]. Or if it’s that if they do get rolling on the notes they’ll look up when they’re done with “just a couple of minutes of notes” and they’re 20 minutes late for their next patient. Etc.

    15. Alanna*

      I just want to say I feel for everyone in this situation. I have issues like this myself. I’ve also managed people with issues like this. It’s tough.

      First of all, there’s kind of a trap in situations like this. You know you aren’t going to fire Grover over the notes. Grover knows you aren’t going to fire them over the notes. And so it can be hard to kick their anxiety/procrastination/ADHD brain into action, because, well, sure, everyone says the notes are important, but obviously the notes aren’t THAT important, because I still have a job.

      This is a grab bag of potential ideas — some for you, some for Grover — take what’s helpful and leave the rest.

      It sounds like the issue is task initiation (just getting started). The hack for this is to stop letting the perfect be the enemy of the good. “Grover, the minute every appointment ends, you are not going to take a breath. You are going to set a timer for 90 seconds and write three sentences about the appointment. Then when the timer rings, you’re done.” One of two things will happen. They’ll get into flow and keep going. Or they won’t, but they’ll have three sentences written.

      Ask Grover what they did differently when they were on the PIP in order to clear the backlog.

      Ask Grover to try a different strategy every day to work on the notes. The goal here is just to experiment. Try 5 different strategies this week to get the notes done and report back on which one worked best for you. If none of them work, you found 5 things that don’t work.

      Start a notes tracking spreadsheet where Grover checks off the note as soon as it’s done. Check this daily. Make sure they know you are checking it daily.

      Set an appropriate size for the backlog. Zero is ideal. 50 is better than 300. Is 10 acceptable? Is there an acceptable but nonzero level that you are OK with? Maybe there isn’t (obviously, eventually all the notes have to get done).

      Lots of people like an “eat the frog” situation where they do the toughest task (ie, the previous day’s notes) first. I personally like to do stuff like this at the end of the day. But Grover needs to find a time and establish a habit. ADHD brains love a routine.

      Finally — and to your credit, I don’t see you doing this — don’t adopt a mentality that Grover should be able to do this, because it’s easy and everyone else can do it. (In fact, I’m seeing on this thread that it’s totally normal to be burdened by notes!) One of the biggest sources of shame in my personal doom spiral (keeping up with my external email — I know, I know, everyone has trouble with this, but I get in a shame spiral where I refuse to even look) is that nobody else has any trouble with it. I’ve made much more progress accepting that, for whatever reason, this is Everest-level challenging for me, while other aspects of my job that other people might find difficult come easily. It doesn’t mean I’m an imposter; it just means that I find different parts of my job difficult than others. Once I start understanding that something really is challenging and it’s never going to be easy, it frees me up to start treating it like a serious challenge — something deserving time, thought, and attention.

      And now, if you’ll excuse me, I think I really do have to deal with my inbox.

      1. OP*

        So many great ideas in here, thank you. Appreciate the credit you gave me in the final paragraph, which is really how I feel! I honestly often feel lucky that documentation isn’t my personal challenge. One thing I am realizing is that I have access to a part of our EHR that makes it relatively easy to see “the list,” but depending on the specifics of how Grover starts (or doesn’t start) a note, it doesn’t show up for them as well, so making something with some easy built-in reinforcement (nothing better than checking off an item on the to-do list!!) might help.

    16. Rene*

      I’d really encourage coaching Grover on getting up to speed with concurrent documentation. It makes my 10 hour days as a counselor much more manageable. Aside from just documentation and billing, if they are that far behind on notes I can’t imagine they’re able to do other administrative tasks like referrals to medication providers or groups.

      My supervisor also pointed out that concurrent documentation means that if the therapist is ever called to testify, they can simply read their notes in court. Whereas if the note is done (much) later, it may cast doubt on accuracy or open the organization to liability.

      If typing is a barrier, I’ve taught several coworkers over the years how to use a handwriting input/alternative keyboard. You write as normal and the program converts that into typed text – and some can read both print and cursive. Just as autocorrect learns your common word choices, these programs learn your specific handwriting as you make corrections. This method can feel more comfortable for “old school” folks who are used to taking notes with pen and paper.

      1. allathian*

        Or even voice-to-text software, if Grover’s more comfortable with dictating their notes. They can be edited at the end of the day to get rid of any errors. Let AI handle the job of a scribe.

    17. kiki*

      Is it possible Grover needs more time in between visits, not just to take notes, but also for a break?I have ADHD and anxiety. I can be “on” and run meetings for bursts of an hour or so, but it takes a lot out of me an I need, like 10 minutes to get a drink, stare at a wall, then hype myself up for the next thing before I do it again. Sometimes there’s stuff I know I *should do* between meetings, but I am mentally not in a place where I can do much, especially something that adds to my anxiety (which it seems like note-taking does for Grover). I know this cuts into the amount of patients Grover could see per day, but it could help with the notes aspect.

    18. Megan*

      I notice one of the comments mentioned not easily being able to switch tasks with ADHD. I wondered if it wouldn’t make more sense to schedule Grover with back to back morning appointments without the ten minutes for not taking, do a later lunch, then all note entry after lunch.

  21. LawBee*

    Tying anything to a July deadline is too far off to make a difference for an ADHD brain – says me, an ADHD brain who lives in the now. July may as well be never. Does Grover have ADHD for real? Who cares, if you can manage them like they do and it works. A lot of time-blindness for ADHD people reads as procrastination, but I don’t think it really is. It’s a true lack of awareness of WHEN and HOW LONG.

    If I were in Grover’s shoes, what would work for me is “turn in notes from every patient seen by end of the day/week (whatever works), no exceptions. Complete 5 backlog notes every week until backlog is caught up.” Very specific task with deadlines that are immediate, not months in the future.

    And find a consequence if the notes aren’t turned in daily/weekly. I have no idea what that would look like for your situation, but it should be something Grover won’t want, that hits them in the short-term.

    1. LawBee*

      Or a positive thing like suggested upstream! Those don’t work on me personally, so I forget to mention it.

    2. hexie*

      Cosigned, though I said this above as well I think it got a bit buried in my long comment (adhd oops).

      Very specific task deadlines, WITH FOLLOW UPS (aka: fill out a Y in this spreadsheet column every time youve done 5 backlog notes, etc, that a manager WILL be checking daily) would really help me. And yes, short term negative consequences are MUCH more impactful than long term nebulous ones!

    3. Antilles*

      If anything, tying it to a July deadline for someone with ADHD can actually make things worse – it’s far enough in the future to be easily able to mentally de-prioritize since “oh plenty of time” and suddenly you’re getting even fewer notes and there’s a backlog of 500 items instead of 50.

  22. word nerd*

    This is mind-boggling to me as a former primary care pediatrician. I have to write my notes day of or I can’t remember what happened. This sort of delay has to affect accuracy of notes, increase liability risks, etc. As far as solutions, I’m guessing hiring a virtual medical scribe is probably financially better than decreasing the amount of time spent with patients (in the adding 10-minute-after-visits suggestion). And I think Grover needs some sort of policy where he is expected to finish all his notes by the end of the day before he leaves the clinic, although I’m not sure how enforcement would work.

  23. Observer*

    I think that the idea for them to record notes then have a transcriptionist put the text in is excellent. On a related note, what is you case management software like? The UI for many of these systems is a nightmare for clinicians and REALLY slows them down. If that’s the story here, having someone handle all of the entry from the voice notes could be a game changer.

    Also, on the pay front. Is it possible for your to restructure Grover’s pay. Like instead of their pay rate being $xK per month, it would be $X-y, and $Y would be money that’s non-salary bonus that’s paid on the basis of performance. So every week with no backlog they get Salary+Bonus and weeks where there is a backlog, they get Salary only.

    That would take care of the legal pay issue, but you should talk to your HR and Legal folks to see if that can be done.

    1. Sloanicota*

      Ooh for me, as someone ADHD- adjacent , getting a bonus for completed notes, even if it was only created by reducing my hourly pay, would really work!

    2. BKB*

      This bonus system is roughly how my husband’s hospital group handles documentation. I think it’s fairly successful for most of the providers—but there are a few outliers who lose their bonus pay

  24. HPMdoc*

    I’m a physician. The burden of documentation can be crushing, I get it. But the OP is wrong that Grover is providing good care if their notes aren’t done. Good clinical care includes appropriate documentation. Otherwise you might as well have not seen the patient. I have worked with colleagues who never got their notes done in a timely manner and it ranged from annoying to downright dangerous depending on what was going on with the patient.

    Grover either needs to start dictating, get a scribe (may not be possible in a rural location), or dramatically cut back on encounters to ensure their notes get done. Because not doing notes may be deadly and that’s just unacceptable.

    1. OP*

      Just want to comment on this one – we’re not physicians, so the stakes are (typically) lower, and in cases when they are not, I flag those specifically and do actually hound Grover until they are done ASAP. And I agree with you overall!

  25. acmx*

    How are they (or were) 300 notes behind? That far behind, how do they remember what notes to input? Are there notes in one place that needs to be copied elsewhere? Because if so, I agree with others that you should look into hiring someone to transcribe the notes.

    1. Emily*

      So aside from the great suggestions already on this post:
      Does Grover have to change locations between every visit? If yes, would it be possible to assign them one room and patients can have the “nurse basics” done in another room, then brought in to Grover’s room? You could then establish a system where the next patient can’t come in until the last patient’s notes are done.

      If Grover already has a dedicated room, maybe having a separate “note station” would help. It would make it worse for me (completing a circuit), but could help some people.

      Could the patient management software be edited so that the next client’s case can’t be opened without SOMETHING in the last case’s notes?

      Can there be an automatic checkbox list created for every appointment? I like ticking off my boxes, personally.

      All of these might slow their turnover between visits down by a few minutes, but at least the task would HAVE to be done.

      (Also a scribe seems perfectly reasonable!)

    2. Heather*

      That’s such a good point. If you’re 300, or 50, notes behind, then when you finally do them— you are falsifying them. It isn’t humanly possible to remember what you did with a patient 49 cases ago and six weeks ago. So then you are making up info to complete and lock the note.

  26. DannyG*

    A couple of thoughts: would a verbal transcription program be a possibility? If Grover is having to manually write his notes it might make it easier, especially if notes could be dictated during the patient encounters. Then they would be ready for final approval at the end of the day. It might even be able to be funded by a grant. The other idea would be to get an assistant (?LPN?) who can be present & again, prepare Grover’s notes more or less in real time for completion at the end of the day or the beginning of the next day.

  27. Eric*

    I wouldn’t be so quick to dismiss compensation options. You could, for example, reduce their salary and have a structured bonus that is tied to performance objectives. And those objectives can include being up to date on notes.

  28. FQHCs forever*

    Can you afford to staff a clinical scribe? I’ve worked with community health centers (including rural ones) who have used both in person scribes and piloted remote scribes. They have found it helpful with provider recruiting and retention so it may worth exploring even though it’s an administrative, non billable position. My clients don’t have trouble staffing a scribe position even in rural areas, it served as a growth pipeline for clinical support staff and HUGELY helped provider workload.

  29. HigherEdEscapee*

    May I suggest thinking about this not just as a serious issue that needs to be addressed for Grover’s performance, but also as an area that might be treated as an accommodation? Grover has stated that they have ADHD and anxiety. Rather than looking at this strictly as a performance and management issue, perhaps treating this as an accommodation issue will allow you, OP, to work with Grover to find a solution that allows Grover to continue in their position treating patients in an area that needs it while also being able to work in a manner that is a win-win for everyone.
    There have been some great suggestions in this thread such as hiring a scribe or administrator, the Pomodoro method, etc. Modeling an accommodating/disability friendly workplace in a rural area would be a huge benefit to so many, including your practice. Perhaps check the Job Accommodation Network (JAN) for more ideas on how to work with Grover to get them set up for success and working in such a way that this is a win-win for everyone.

      1. HigherEdEscapee*

        You’re welcome. My graduate work has been at the intersection of labor and disability so my natural reaction to your letter is to look at this from that perspective. To me this looks like a situation where open communication from a supervisor who clearly cares about their staff with a staff member who, buy their own admission, has conditions which can be frustrating and productivity limiting is an area for growth and positive change. In my mind, this isn’t just a management question, it is also an accommodation question. Best of luck to you and Grover, OP.

  30. Zanshinart*

    Is it practical to hire a scribe to document alongside him? I – in a rural, underserved area – have received PT from a superb PT for whom the agency
    hired a scribe to sit in with us and enter computer notes throughout the visit that the PT could review, edit, sign off on later.

  31. Chelle*

    Is there budget to implement Dragon transcription software (so Grover’s notes can be captured more easily through dictation), or hire a scribe for them who could take the documentation off their shoulders almost entirely? Obviously neither of these solutions is free, but given the reimbursement I’m sure you’re losing due to timely filing issues, they might pay for themselves.

  32. Scout*

    This might be difficult since you’re rural, but can you get Grover a scribe? There are also remote scribe services, where the scribe is present by Zoom basically, but I have found that in-person works better if you can swing it.

  33. M. from P.*

    Could Grover be paid per note rather than per visit? Maybe with some low base pay plus bonus pay structure?

  34. Healthcare Manager*

    I’m an ex-mental health clinician and I remember the days of note writing.

    If Grover has anxiety about capturing the content can you implement a safety net, ie you will check and let them know if any notes need more information/clarification.

    You set this up at a frequency that makes sense for YOU, you be clear that as management the responsibility is on your head not theirs. You don’t even need to tell them how many of their notes you’re going to check (cuz otherwise that’ll start anxiety about how many you’re doing), and in fact you’ll probably find that you won’t even need to check at all.

    Part of it is about creating a safe space and team comradely about the record keeping.

    There’s a lot that Grover can do to manage anxiety about this however I want to focus on what you can do.

  35. Dental floss rancher*

    I’m a physician with ADHD and anxiety. Getting notes done is a major issue. I get stressed about getting behind and making the next patient wait and then I don’t do my notes until the end of the day and the I just am so done and it takes so much longer to do the notes later in the day so I get behind and it gets out of control. This is what has helped me stay on top of notes. I finish my note after each patient. Patients are booked back to back and I can’t change that, but I’d rather be a few minutes late to see the next patient if it means getting notes done and maintaining my mental health.

    I’m not in the US and I’m not an employee so there is no duty to accommodate. And if patients are mad that I’m 2 minutes late seeing them (literally two minutes, if I control my day like this, I don’t run behind unless there’s an emergency), they can go find another doctor. I also block of two 15 minute spots in my day as paper work or urgent tasks so I can catch up on notes that were delayed because of emergencies. I’m a bit sneaky about this because we are also exempt from employment laws that allow us to take breaks but I’ve figured out a way that makes it work.

    I have to sneakily build this in myself, but OP, if you have the power to let this provider schedule things in a way that lets them get their notes done, please try it. My exact way may not work and it may take some trial and error. There are also unlisted Facebook groups for physicians, PAs, NPs, and other clinicians with ADHD, and if Grover is in any of the bigger Facebook groups for whatever kind of clinician they are and they message an admin, or post in the group, someone will point them to someone who can add them. Those groups are full of ideas.

    The hardest part of being a clinician with ADHD is having a manager who wants to support you, but it sounds like Grover has that in you OP, and there’s a good chance they’ll be able to find a solution if they can reach out to other folks with ADHD and you’re willing to try things. The thing about ADHD is that sometimes we don’t know what the solution might be until we try a few things. And the lack of motivation is usually secondary to how overwhelming it is to deal with this, and the motivation usually comes when a solution starts to work.

    1. hexie*

      “the lack of motivation is usually secondary to how overwhelming it is to deal with this, and the motivation usually comes when a solution starts to work” <- this is so brilliant I want to print it out and frame it, I have never seen this explained so concisely and I'm going to start using it in my own work and in making myself feel better when it takes me ages to get going on something!

    2. umami*

      ‘And the lack of motivation is usually secondary to how overwhelming it is to deal with this, and the motivation usually comes when a solution starts to work.’

      Wow, thank you for stating that! That makes so much sense.

    3. Flying Fish*

      All this. I’m a Physician Assistant and have the same issue sometimes.

  36. Healthcare Manager*

    Alison – would it be possible to add in a reminder at the top of the comment section for all to be mindful of using correct they/them pronouns?

    It’s been really disheartening to see a large number of comments using gender specific ones.

  37. Dental floss rancher*

    Also as a physician with ADHD, spending the last hour of the day in OP’s office doing notes really doesn’t sound horrible to me, it sounds kind of nice. It sounds like body doubling, which is often a really good way to get tasks like this done if you have ADHD. I bet if you suggested it as a thing to try to see if it helps, Grover wouldn’t necessarily see it as something negative. I would love it. I will sometimes take a laptop over to a part of the clinic where other people are still working to sit do paperwork if everyone in my usual area has left for the day.

    1. Shorty Spice*

      That’s a really great point! A group note writing session scheduled at the end of each day would be a really nice connection opportunity.

  38. ES*

    I don’t know what type of medical service Grover provides but consider getting them a scribe or dictation service like dragon. Do you have MAs that can help prep patients, complete much of the note that isn’t new such as vitals, PHQ, past history? Can they prep the note in the mornings and make a plan so they can complete the notes in real time? They might need a break midday between patients to catch up on morning notes. Give a similar break at the end of the day. Sure, fewer patients are seen but this might help them provide better care and complete notes.

  39. Kayla McLoughlin*

    There are medical scribes for exactly this reason. Is it an option to hire one?

  40. LB33*

    Does the rural location mean it’s equally hard for Grover to find work elsewhere? Because if i were him I think i’d be looking to leave.

    Bouncing around from a PIP, to a possible firing, two weeks vacation cancelled – that’s not going to make him more enthused.

    Not saying you have many options here, just be prepared for him to leave regardless

  41. rssees*

    Can you hire a medical scribe? I’ve had some for my appointments and it’s been great, because the scribe does all the writing and the provider does all the talking.

    1. Pippa K*

      I see that OP has added that a scribe won’t work in their circs, which is too bad because otherwise it sounds ideal. I recently saw a surgeon who had a (licensed) physician’s assistant as his scribe, and it seemed to make the appointment both more efficient and substantively better. The PA started the visit, took history, etc., then the surgeon joined us, got briefed by the PA, asked me if I agreed with the summary and wanted to add anything, and then dove into detailed questions and explanations, with the PA scribing the whole time. I got the notes later and they were accurate and detailed.

      I know it’s a common thing in some practices, but I hadn’t had a doctor who used a medical scribe before and I really liked it. Seems like it frees up the physician’s time, possibly to see more patients, and served all our interests well. I wish Grover could have something like this!

  42. I'm fabulous!*

    My apologies – do you think setting a deadline for them will help? (Sorry, I mistyped).

    Allison – please delete my first post due to my error. Thank you.

  43. SleeplessKJ*

    Can’t you keep Grover but post the position? If Grover improves with intervention, you can always withdraw the job posting. But in the meantime you will have applicant at some point and then will at least have options.

    1. OP*

      Good question. We’ve got an opening posted for the person who retired. I suspect HR wouldn’t allow us two at once while one is filled, but we are “perpetually open” for what I hope is a good candidate eventually!

  44. Data Bear*

    If Grover is correct about this being an ADHD/anxiety thing, you are not going to solve it with punitive measures. Not permanently, anyway.

    The root problem here is that folks with ADHD have screwed-up dopamine circuits that make it really, really hard to work on tasks where the only motivation is delayed. You sit there, trying to do the thing, *wanting* to do the thing, knowing that you NEED to do the thing, and your brain just… won’t do the thing. Until the negative consequences are so imminent that panic takes over and you get enough adrenaline flowing through your system to make up for the lack of dopamine that you can function. (This really sucks, by the way. It’s a lousy way to live your life.)

    This is why the PIP only worked temporarily: it gave Grover a burst of crisis-energy that they used to burn through that backlog (because let me guess: they didn’t work through it a little at a time, right? They did it in a big burst?), but it didn’t do anything about the fact that there’s *something* about the process of documentation that throws Grover into executive-dysfunction procrastination. Likewise, the threat of no time off in July may get them to do the same thing in June, but they’ll backslide again once they’re back.

    Contra to Alison’s usual advice, I don’t think this is a problem that will be solved by clearly communicating expectations. It sounds like Grover already knows and understands it’s a problem, and probably feels really bad about it. This is a problem that needs to be addressed by changing the motivational environment of the situation.

    If you can discuss it with Grover and figure out what the thing is about reports that makes them hard, and then change that thing, that would be the best solution. Is it the need to get things right? Do notes feel like wasted effort? Does something about it make Grover feel inadequate or judged? Is there some set of distractions that they need to be shielded from in order to focus? Is there a source of pressure that needs to be removed?

    But that may not be possible. You can try providing extrinsic motivation. Does Grover get any positive feedback for doing notes? Try asking them to do a set of notes as a favor for you, and being really appreciative about it. It’s dumb, but sometimes there are things you can easily do for other people that you can’t do for yourself. You can also try body-doubling: if you have a time when you can be there with Grover while they do notes, sometimes that’s all it takes. Maybe even just setting aside a scheduled time for notes. Maybe there’s a way to gamify the documentation process to make it novel and interesting. Try sitting down with Grover and googling “ADHD productivity hacks” to see if you can find a promising strategy.

    Of course, one of the most effective fixes is getting medication that makes your brain work better. But that can be a whole ‘nother set of obstacles to overcome…

    1. Data Bear*

      Another thought (which I mentioned elsewhere) – it may be that a significant element of the problem is task-switching. Some ADHD folks have a really hard time changing gears, and it can be nigh-impossible if you know that you’re just going to have to change back shortly afterwards. Can Grover’s work be rearranged so that all of the note-writing happens in a single block?

      1. cncx*

        This is me. I have a hard time changing gears. I work in a helpdesk setting and the worst job I ever had was with a boss who wanted to drag me off on random side quests and yet expect me to answer the phone (which rang…as much as a normal hotline rings, so a lot) and spend thinking time on more complex tickets at the same time. A nt person might be able to do two of three…I was absolutely blocked by the constant interruptions and especially his side quests. I now work in a place where I’m either running the phones or I’m on my thinking tickets, and no random side quests.

    2. Prefer my pets*

      This is such an excellent comment. The pandemic combined with a job change, a cross country move, and some other major personal upheavals broke every ADHD coping mechanism I’d developed in my lifetime. The pure despair of *knowing* you need to do the thing but just somehow not being able to do the thing until panic sets in is the most maddening part of ADHD. It’s like there is a bullet-proof glass wall between me and Doing the Thing and everyone is saying “well, why don’t you just do the thing you know you need to do?”.
      I know more ADHD people than I can count in this boat…the pandemic & the associated situations broke our non-medication adaptations, and then when we try to get medication there’s massive shortages in both the actual pills and providers to prescribe them. We’re all in giant pits trying to figure out how to climb out when our ladders are gone.
      I’m interested in this comment section far more for what to do as a Grover in despair, failing in every aspect of life after a lifetime of overachieving (hyperfocus and a racing brain that never turn off have benefits in some situations).

  45. Victoria*

    If a scribe wouldn’t help but there is some budget and you’re willing to, can you hire someone to be a Grover Chaser? Not literally that as their job title, but a part time admin person who as part of their tasks can monitor the backlog/chase Grover/hold their hand/be present while they write their notes/issue regular reminders or whatever else you both decide would help? Then at least you’d be freeing up all the brain space you’re currently filling with managing and chasing.

    Micromanaging is time consuming, so if that’s what works and is needed, see if you can outsource that bit.

  46. Daryush*

    Finally a question about my industry! Sounds like you and Grover are both letting the overdue notes pile up, which I’m sure is feeding into their anxiety. What if you run a report every morning for Grover to show missing notes/charges from the previous day, and make it clear that this has to be completed by the end of day? Keep the backlog from growing unmanageable.

    I would also take a look at Grover’s contract. How much admin time do they get vs. patient facing hours? What are they doing during their Admin time? Are they doing tasks that they should be delegating to MAs or the front desk?

    Last thing: next time you renegotiate contracts, can you make part of this provider’s pay a bonus that is contingent on billable visits? Like if Grover’s schedule allows for 300 appointments a month, and you have a 10% no show rate, then Grover needs 270 billable visits (with complete documentation) to get their monthly bonus.

    1. saskia*

      OP, look at these great suggestions!

      Also, seconding the idea above to post the position now instead of whenever Grover finally leaves.

      1. OP*

        Agreed they’re great! Especially second and third – given the setting, we do more “case mgmt” types of tasks than in other settings, but I haven’t checked in on Grover’s support staff usage in a bit. Re: compensation, bonuses are decided one level up from me, and Grover has been losing out in this regard (still getting small year-end bonuses, but not as big as available for their seniority as someone with adequate performance), but a monthly structure and clear visit guidelines is so appealing to at least consider!

  47. Anastasia Beaverhousen*

    I feel as if I am reading this about the office I work in, another thing to consider is that if Grover has peers they are also aware of his under performance and there may be resentment that they are meeting the goals set for them and he is continuously allowed to miss them. If you can’t fix Grover can you offer incentives/rewards to those who are meeting their goals and baseline expectations. Not showing appreciation for those who are doing the work well will compound resentment and may lead to other staff leaving.

    1. Also ADHD and anxious*

      This isn’t the worst idea, if unkindly phrased (“fix Grover”, “not showing appreciation for those that are doing the work well”). ADHD is a disability. It’s not something to be fixed, it’s something that workplaces need to accommodate. And Grover’s ADHD and anxiety may actually be helping them in their interactions with the clients, even though they’re causing struggles with the notes.
      But incentives and appreciation go a long way toward making a workplace pleasant for everyone. As a person with ADHD who probably needs external motivators, Grover would benefit from being appreciated for the things they do well and for being praised when their notes are on time, and so would every other person who is able to complete their notes in a timely manner.

      1. OP*

        I appreciate both these comments. Re: resentment, it me! I am resentful. Not because I think this is a thing Grover is purposefully doing as opposed to a manifestation of mental health issues, but because I have to spend some much time on it, as opposed to actual clinical supervision, which is a source of professional joy for me (and I do enjoy supervising Grover specifically). I appreciate the space to acknowledge that, as I’m sure it’s impacting my problem-solving.

  48. yet another ADHD folk*

    If a scribe or transcription service/software for recorded notes is not in the budget treat this as needing ADHD accommodations rather than how to punish for poor performance.

    1: Set artificial deadlines: Say, weekly, they need to have completed x number of notes, and it needs to be reported to you at a certain time. A task with no deadline is a task that will not be done. This metric can be shifted if they get caught up.

    2: It doesn’t seem like padding time after appointments is actually working. I know that I often need that few minutes for myself in a busy schedule. Can you experiment with a dedicated block of time daily to do paperwork for a week or two and see if that helps? (If Grover isn’t good at settling into deep work, this may not be successful)

    3: While scribe/transcription would probably be best, the above suggestion of a template is also a great step, particularly since you describe that anxiety over what to write is part of the problem. Can you work with Grover to develop a basic template that’s well-suited for the notes they need to take?

    4: Acceptance. Grover will probably always have a backlog. 300 was clearly unacceptable. 50 is a great improvement, but also excessive. But you may want accept that the goal isn’t going to be “no backlog” but 5 or 10 to account for the reality of ADHD.

    5: Feed the dopamine by gamifying notes. I don’t know exactly what this would entail, but sometimes just clicking a checkbox when something is complete is enough to keep me going.

    1. raktajino*

      >Feed the dopamine by gamifying notes.

      My team has to work through really boring spreadsheet tasks and we have used these as visual rewards for progress:

      1. Label magnets or sticky notes to represent the chunks of work. Now they’re something physical, and moving them along from backlog to wip to done is more satisfying. (This one is a classic for a reason, but it takes management.)

      2. is a virtual hike. You enter in the number of steps/miles/km you’ve done that day, and get photos from your “hike”. To do this with a spreadsheet, I made a conversion between “number of rows” and “miles in this trail.” Every evening, someone would enter in the “miles”.

      3. I don’t remember exactly how I set this up, but I had a workbook to count the number of completed rows. In another tab it displayed a random picture from a site that would let you hotlink photos, the url for which was randomly generated. Somehow I got that hotlink url to change every ten rows we completed: Every ten rows, we got a new random picture. The random reward at regular intervals was ridiculously motivating to everyone on my team, not just ADHD me.

      1. Mac (I Wish All The Floors Were Lava)*

        These are all fantastic ideas.

        OP, one thing I haven’t really seen addressed in the comments yet is that part of the problem may be that this is a task that takes what they clearly feel good/capable about in their job (interacting with and directly helping patients) and sucks all the life/humanity/immediacy out of it. I haven’t worked in healthcare, but in education, and although I always had stellar feedback on the student-interaction side of things, I was TERRIBLE at anything paperwork-related (entering attendance/testing data, for example).
        The suggestions from other commenters for body-doubling (or what I’ve always just called having a study-buddy) are in part addressing that need to inject some human component back into the task. I think that another way to bring back some of the humanity can be to use the idea of the template for the notes, but in Grover’s case, the first prompt could just be “How well do I feel I connected with this patient today?” on a scale of 1-5. Right away, there’s a little hit of dopamine, because I guarantee that’s a question Grover knows the answer to immediately. That is what they are good at, and giving them a visceral reminder of that in the midst of a horrible chore they feel really bad at, will hopefully disrupt the dread cycle, and instead make them eager to explain what happened to make it go well (or what to do to make it better next time). Assuming that this is not a detail that is usually found in medical notes, it obviously can be deleted from the first line as soon as the rest of the notes are written, but I think for me, just having that qualitative rating of the personal interaction would be such a helpful way to flick the switch in my brain into ‘ok, now I’m analyzing & describing what happened in that human-to-human interaction’ mode.

        1. OP*

          Oh, I love this framing! Thank you. I don’t think documentation has to be that way at all, in our specialty, but I know Grover gets stuck in that trap.

          1. Scandinavian Vacationer*

            My best friend is an OB/GYN who fell into this trap. She never learned to type, and felt it was rude to write in the EMR in front of the patient. Thus, she spent at least 2 hours/night charting her visits after her last patient.
            Two ideas:
            1. have Grover review anonymized notes from other providers, they may see that notes can be quite standardized. When I showed my friend the notes from my mom’s cardiologist, she was amazed at how ordinary/average/not a big deal the content of the notes. She said “Really quite plain” in her reaction.
            2. How about suggesting Grover try narrating to the patient while typing in the EMR? My primary care doc (in his 60s, so typing/EMRs were a big transition for him) would do this. “Now on your last visit…I see it has been X time since your last labs…you mentioned ABC a year ago, how is that now?” It gave me confidence as a patient that my doc was actually researching my history in real time during our visit. My doc would also google recommendations during visits, ex: here’s a book to consider, how about this OTC lotion? Again, a perfect use of the laptop that actually benefits the patient immediately and improves care.

  49. DrMrsC*

    I didn’t see confirmation anywhere in the comments about Grover being salaried/exempt, but I’ve seen the behavior described in multiple clinical settings in my own healthcare career. My current department has clear policies about things like the timeliness of documentation and attendance. We are super rural too though and I understand all to well that sometimes you bend to avoid the burden of an extended job opening. Our clinical staff are all paid hourly, so the problem has been getting the job done without going overboard on overtime. If Grover is salary/exempt though… there is really no excuse here. You either stay until the job gets done or come in early to wrap up one day before you start the next one. If Grover isn’t doing their job within their scheduled hours, the expectation should be that they are working more hours to complete the tasks. (This assumes that I used salaried and exempt correctly, which I am always paranoid about messing up…) Also, having seen something like this play out at least 3 times professionally – issues like OP is having with Grover inevitably spill over to your other staff. My guess is that at least a few would rather take on the burden of picking of the slack of an open position rather than feel like they are always being held to a different performance standard.

    1. DrMrsC*

      Just to add, my guess is that Grover may be something like a Physical Therapist as opposed to a Physician or NP/PA level “provider”. If so, then in rural healthcare, that is a chasm of hierarchy in terms of what “extras” like a scribe are available to you. That said, if Grover self-disclosed the ADHD etc… to OP, it might be worth exploring a formal (ideally structured) accommodation of some sort through HR.

      1. OP*

        Yes to this! As non-physicians, a scribe would be an unusual solution for us. That said, I have the data clearly available to me that we bill several times more than our (exempt) salaries, so I still really appreciate people’s nudges to consider it/crunch some numbers.

  50. Anonymous Autie*

    As someone with autism, possible ADHD and executive function difficulties myself – definitely ask Grover. If you’d asked me “what would you do if you were me”, I would have given the same response as Grover – “probably fire me”. But framing it more as “we need to get this done, what might help you get this done” will get their brain thinking along more productive lines, particularly if you give them time to think it over and come back with ideas.

    You don’t need any more practical ideas from me as there are several ADHD-ers on the thread already, but some that I’d echo are that 10 minutes isn’t going to work – I’d be too focused on the next patient meeting and that’s not enough time to switch tasks and condense my thoughts. An hour (or a bit more) at the end of the day that’s a focused “block” of time for writing up notes, reduces the burden of task-switching and so is easier in terms of executive function. Whether or not it helps for that to be independent or in your office is best to ask Grover. There might be a role for you there around the anxiety as well, if you are willing, if they are able to ask questions or bounce things off you to get past the perfectionism block. (It would likely not take much time, but just help them get started.)

  51. Millie's Mom*

    My facility puts providers on a “suspension” if they get too far behind in their notes. I’m in the surgery dept so only really see this work for doctors who have surgery privileges here – if they don’t complete their documentation, they cannot schedule further surgeries, or perform the surgeries already scheduled. As far as I know, this hasn’t actually impacted patients, b/c the providers always seem to be able to get the documentation done when they are put on suspension. I’m don’t know that something like that would even work in your practice, OP, but maybe some variation? Maybe not at all, but I thought I’d throw it out there anyway.

    1. OP*

      I have considered it, but not thoroughly, and will. The thing I worry about is if this would be shame-triggering if Grover’s caseload knows why they can’t schedule with them.

      1. Millie's Mom*

        Yeah, I’m not sure it’ll work in this instance. In a bigger practice, with a practice-wide requirement, it works (mostly!), but if it’s just for 1 person, it kinda feels targeted. And in a rural setting, too, it makes it tricky.

  52. Lhooq*

    This is a tough situation, but I may have some advice for one small aspect! Above, the OP says that anxiety is part of what makes Grover avoidant, and I’m a writing teacher who works with LOTS of students with anxiety/ ADHD/ writing anxiety/ various neurodiversity. Here’s some things that can help:

    1) Can Grover write notes OUTSIDE of the final form? A Google doc or word document would be perfect. Sometimes thinking of something as a “final draft” raises the stakes, which leads to anxiety and perfectionism. If they’re written somewhere (even in note form), that makes it SO much easier to enter later.
    2) Change the font to something stupid. I like purple comic sans. This makes a piece of writing look less serious, which lowers the stakes (and therefore the anxiety). It sounds like dumb advice, but it works.
    3) For the backlog, I love Alison’s advice to do it in small chunks, like a few a day. The more you can encourage Grover to do SMALL writing tasks, the better.
    4) OP- you mention that you review Grover’s notes and give feedback (which is awesome!), but do they ever look at yours? Sometimes it’s easy to get lost in “Ahhh! I’m doing it wrong!” mode if you can’t see other models of what you’re supposed to be doing.
    5) If Grover can’t do them after each appointment, that might just be part of the process. It might be better to focus on doing them at the end of the day (or the end of the week, but that sounds overwhelming). Sometimes, pushing someone to write can become counterproductive and activate feelings of failure.

    I hope some of this is helpful!

    1. OP*

      Hah, I love the font suggestion! Grover can read my notes, and we sometimes review them together to remind them that “done” doesn’t need to mean “spectacular” (I am clear that we’re reviewing for “standard practice” purposes, not that I am some paragon of documentation). One thing I will be doing as a result of writing in is compiling all these suggestions together so I have a bunch of wisdom all in one place, and see what might fit for them.

    2. Cyndi*

      In the same vein as “changing the font,” when I have to write something I’m really stressed about, I find it’s a LOT easier to get started if I zoom out or shrink the font so small that I can’t actually read what I’m typing! Though this probably requires a certain degree of touch typing ability that Grover may or may not have.

    3. retrowaveRecluse*

      This was a very helpful practical comment – it may not help OP and Grover but I (neurodivergent) have found such tips helpful in the past and will probably use them to, oh, say, handle a backlog of written work which is completely non-critical and has fallen through the cracks because of anxiety and burnout. Thank you.

  53. saskia*

    I used to work in a hospital position and document on all the patients at once during the last bit of my shift. Even if I saw them throughout the day, I’d do it all in a block and use my handwritten notes from earlier to job my memory. Has Grover tried this method?
    I’m concerned the backlogged notes aren’t 100% accurate.

  54. hi there*

    I love Alison’s kind approach here. I don’t think “micromanage” is the best phrasing because of the stigmas attached to it, for both OP and Grover. However, “time management” seems to be a critical area for improvement. There are a ton of resources out there that both OP and Grover can use to provide some more structure around “what will help here?” One useful starting point might be the YouTube channel “How to ADHD,” whose short and ADHD-friendly videos will validate their feelings AND provide succinct interventions to try. Just to say… neither of you are alone, and yes this is hard but it can be done IF Grover commits to the most desirable outcomes (i.e., no backlog and a July vacation).

  55. fgcommenter*

    and this situation leads me to be hesitant to hire anyone I’m not extremely enthusiastic about

    Since the problem is caused by being short-staffed, be willing to hire people that you aren’t extremely enthusiastic about.

    1. OP*

      Fair. I was thinking specifically of one interviewee who had a yellow flag regarding practice ethics – I do think they were worth avoiding and would continue to do so. At this point, I would take any applicants just to see how it felt to have a potential option!

  56. DVM*

    As an ADHD-having anxious procrastinator, same-day deadlines have really lit a fire under my a$$. I realize that what I need is a much shorter limit on how long I can procrastinate before I’m in trouble and I am much better able to manage my time. I am now able to speak up when I am overwhelmed because it is easy to see it coming that I will need help or flexibility.

    1. kiki*

      Yeah. I really like the idea of flexibility and scheduling my own work, but ultimately I do a better job when I have daily deadlines with some sort of consequence/ stakeholder. Even if I don’t get “punished” or can get out of it by explaining why I didn’t complete something by the deadline, just having a real deadline gets me to push past my anxiety and get it done.

  57. Coaching Works*

    What about a Behavioral Health Coach/Life Coach? I know people think we’re namby pamby new age crap, but actually a good coach would be able to help Grover get back on track and stay that way without LW being driven to utter distraction. As long as Grover is willing to put in the work and is motivated to change, that is.

    The coach would also be able to identify if they needed a therapist to help them as well. There are many strategies and problems that could be causing this, and having someone to help them work through this would be helpful to Grover and LW. I know because I’ve helped a lot of people with very similar problems as a Behavioral Health Coach.

    Perhaps LW could suggest this as well? Or even require they try a few sessions if they have one available through their insurance?

  58. DryEraseAficionado*

    I struggle with many of the same getting in my own way procrastination and avoidance issues. I wonder if Grover would have an easier time with a time based system rather than number based? Finish today’s notes and work 25 minutes on the backlog instead of today’s+X number.

    Another strategy that works for me is to set a goal (I am going to do these 7 charts today) and estimate my time for each one (15 minutes each) and then play a game with myself to see if I can meet or beat my estimate. I find this gives my brain something else to grab onto and there is something I can win. Even if it is just my own silly game.

  59. TG*

    Okay so thinking on this for a few…
    Could you hire an intern to read the notes or scribe them from Grover to help them catch up?
    Could you require that a certain number be done each week – that way it still gives them the option of doing that when they can find the time?
    Help them make a task list/email reminder that they need to do this – sometimes for people that have an issue with time management, having the reminder helps (I admit I have been there and reminder help me)
    Explain that this is ruining the otherwise wonderful care they give and if they could just manage this, they would be on a much better footing at work and allow their clinical work to shine?
    Hoping maybe this or other’s thoughts help!

  60. word nerd*

    If concurrent documentation is fine and Grover has time between appointments to document, would it work to set up a system where the basic expectation is that they finish and submit their note before going to see their next patient, with a little wiggle room to override rarely when it’s not possible? Maybe they have to forward their note to someone/some generic box each time they submit so it’s clear that they are doing this at regular intervals after they have finished each visit, and this should be for 90+% of notes. I know I felt bad sometimes about charting in front of patients during visits because I don’t feel quite as connected and concentrating 100% on them, but I think that’s far better than being so behind on notes.

    1. word nerd*

      One additional thought: does your electronic health system make it easy to print out “after-visit summaries”? If so, maybe the patient can be prepped from the beginning with the expectation that they will get an after-visit summary at the end of their visit with Grover (which I think is nice to provide for underserved populations anyway summarizing recommendations/next steps). Then that provides the impetus for getting documentation finished and printed before moving on to the next patient.

      1. Scandinavian Vacationer*

        YES! My mom’s cardiologist has this system, the after visit summary is printed out at the reception desk when the patient checks out. Really just a few line summary, with the NEXT VISIT printed prominently. Maybe spin this as an improvement for patient satisfaction?

  61. NoOneWillSeeThisComment*

    I do think it could be a bit over the top to say people’s health would suffer if you lost Grover…I mean, we do live in a free world where patients can go somewhere else. Yes, I realize those other options may not be as easily substituted, but let’s not start labeling choices out of our control.

    It’s interesting that the PIP worked, which I think only undermines the excuses Grover might have. I am assuming this isn’t a skill issue (for lack of a better term) like a general dislike/unfamiliarity with computers?

    I like Alison’s general suggestion of calling it out as a problem Grover can/should help come up with solutions for. I’m also wondering if there are any professional resources available? I know I personally benefit from something like a day course to brush up on skills related to my job. Something related to organization, time management, or even how to manage anxiety in the workplace (who doesn’t need that LOL) might be an option?

    1. Also ADHD and anxious*

      “It’s interesting that the PIP worked, which I think only undermines the excuses Grover might have.”

      Probably incorrect! Most likely what happened was that the PIP created a sense of urgency that Grover doesn’t have in their regular routine. Grover needs to find a new way to create that sense of urgency. People with ADHD have a legitimate disability that makes it difficult to do tasks that aren’t urgent, interesting or new. It’s not fun; you spend your whole life berating yourself for not completing tasks that you know you can quickly and/or easily do if your brain would just let you actually do them.

    2. OP*

      Hi! I appreciate your comment, and would gently like to correct an assumption you’re making about choices in this healthcare environment: “I mean, we do live in a free world where patients can go somewhere else.” When I say rural and underserved, what I mean is that the nearest clinic to ours is a 45-minute one-way drive away, and many of our folks lack both reliable transportation and the internet access needed for telehealth. I could elaborate here, but hopefully that gives you additional insight into what practice in non-urban areas can be like.

  62. Sarah*

    I’d honestly look into accommodations- can you get dictation software like Dragon, or hire a scribe (in person or remote?) Often one extra appointment per session will more than pay for the scribe, and overall save the provider time. And the scribes get valuable experience for when they apply to Med/nursing/public health school

  63. American Couch Wizard Society Member*

    Oh man, what a mess.

    In a previous life I had *exactly* this problem–we weren’t rural but the role was difficult to recruit for, my really clinically excellent provider was 300+ notes behind due to anxiety/perfectionism/procrastination.
    We tried a whole bunch of the same things you are describing, including giving them extra time, sitting down with them, I bought them a timer…

    In the end it was all for naught and I had to fire the provider, and our previously strong relationship was ruined because at that point (2 years in) they had reached BEC status for me. And also I had to personally close 200+ notes (not to bill, but just to get the open notes closed in the system.) That provider ended up going into a semi-concierge practice where her incredibly detailed notes and 40-minute visits were an asset to her rather than a problem, and everybody was much happier.

    I get that you’re saying that a scribe wouldn’t work, but is there really NO WAY to make a scribe work? Even an MA or something who is acting as a scribe and documenting the notes for Grover to close later? Or one of those virtual scribes who works through the computer? Because I do not think you are going to turn Grover into a note-writing machine, and for everyone’s sake, I would recommend trying to find a way to focus on Grover’s strengths and avoiding their weaknesses.

  64. ADHD(no H; all inattentive)*

    So, knowing that Grover has ADHD, and since I am learning quite a lot about it myself right now, I don’t think micromanaging them is going to work. What they (or you) need to do is to figure out how to make him WANT to do the administrivia, or make it easier for them to do it.

    Tell Grover to look up the connection between (lack of) dopamine and ADHD – that’s my personal big AHA moment this week, and it really explains SO much about why I have a very hard time being motivated to do things that I’m not deeply interested in (and sometimes, not even things I AM deeply interested in). There are some practical ways to incent yourself to do things you don’t particularly enjoy, that seem impossibly boring, or that just are not fun.

    Also, look at technologies that could help. Does Grover take notes on a tablet or laptop? That would eliminate half the issues of documentation if he can just take his notes in electronic form in the templates he needs for the reports. Could he use something like ChatGPT to summarize his notes – I’m telling you, it’s not perfect, but wow, is it ever handy to toss my notes into it and let it summarize them for me.

    Since the anxiety and ADHD have been disclosed to you, can you encourage Grover to access company benefits like EAP services, or encourage them to review their medications with their doctor? Clearly, whatever they are doing now is not working for them. Your perspective on what the issues are might really help Grover to communicate the issues to their doctor, so they can find medication that does work. (Personally, had someone tell me today that they can see that my meds are not working – it’s hard to see from the inside, but I had suspected the same, and it was very validating to hear it from someone objective).

  65. bat*

    Apologies if this has been suggested already, but as someone with some writing anxiety as well:
    -How long do the notes need to be? Is Grover stressing about producing something in-depth when really, a couple of sentences would be better than no note/a really delayed note? Personally, I experience this pattern: 1) “I want to write a good [whatever, cover letter/term paper/etc] and feel I there will be negative consequences if I do a bad job” 2) “I don’t have the time or mental focus right now to write a Good Thing” 3) “I’ll get to it later when I can do a better job.” Rinse and repeat. Is it possible to have a more explicit conversation that lowers the expectations for the note itself? Length, grammar, how detailed it is, etc. Also telling Grover explicitly that nothing bad is going to happen if the note is just “fine”, not “great”. I wonder if they have experienced harsh feedback in the past on the quality of their writing.

    1. lilyp*

      I would also think through, and talk through with Grover, what the low end of the “acceptable” quality spectrum is for these notes and what the bar truly is for “better than nothing”. I imagine there IS a quality level that is “worse than nothing” or would be an equally bad performance problem (e.g. incoherent or incorrect notes), so what’s the bare minimum above that? Are complete sentences necessary? Are typos or grammar mistakes acceptable? Would a bulleted list of key words be fine?

      Grovers notes now are great, but I suspect they’re putting in a lot of time, energy and effort to reach that quality level, and I bet they could speed things up by lowering that quality bar, but that might be very scary for them if they don’t have a good sense for what “good enough” looks like.

  66. Longtime Health Care Admin*

    Get Grover a Medical Scribe asap. It will save both you the head of of note completion. they have remote scribes that join clinic visits by audio or video or go off a recording of the visit. the provider just has to review and sign.

  67. Engineer*

    At my job we have a weekly email hour where anyone in the group can meet in a conference room, and we individually answer our own email backlog. Could your team do something similar?

    You said their notes are fine. I imagine Grover could actually be spending a lot more time on notes than rest of your staff. Could Grover’s notes contain less information? Maybe guidance on what is minimally required would help. Do you need complete sentences or would bullet format suffice? Could you tell Grover to set a time limit on the notes (ie should not take more then XX min to fill out)?

  68. Pam B*

    I used to work in healthcare, and have family who work in health care in a small rural community, so I understand some of the pressures your likely facing. I absolutely agree that timely documentation is important (from a patient safety perspective and a reimbursement/financial sustainability perspective), but I’m also wondering about the fact Grover has been in position for 10 years. You say your workload is unmanageable, and that Grover typically sees fewer patients per day than you. Still, could they be experiencing burnout? Burnout is very common for rural health care providers with all the additional tasks and workload they are expected to complete in understaffed places. Burnout for all healthcare providers has also been increasing considering that we are just emerging from a global pandemic that stretched many rural health systems and providers beyond their breaking point. How has your workplace handled this for everyone, not just Grover? How are other providers in Grover’s position handling this? What about staffing in support/admin positions that help keep tasks off of the providers workload? Also, was your rural community supportive during the pandemic toward health care providers in your position, or did your interactions with patients get hostile and political (in regards to vaccines, ivermectin, etc.)? Any or all of these things could have contributed to Grover’s issues of anxiety and avoidance.

    If overworking or burnout is affecting Grover, not approving their 2 weeks of leave could do more harm than good, especially since you mention that you think they are capable of completing their current backlog. What makes you think this? And what supports could be put into place to keep their backlog from growing? Alison’s suggestion to ask Grover what they needs to finish up the backlog and keep it from coming back is spot on.

    In addition to the other suggestions shared here, maybe having providers at Grover’s level share strategies with each other on how they keep their documentation manageable? Or having templates of common patient issues, care plans, and diagnoses codes that can be used as a starting point and then individualized for each patient? You could also could share example notes (that are redacted for confidentiality) to get inspiration of what level of documentation is expected. If Grover has any level of perfectionist tendencies, they may be spending too much energy on the quality of their documentation, when they need help calibrating to focus more on quantity.

      1. OP*

        Agreed! I should have mentioned this earlier: YES Grover is burned out. We talk about that openly. They report it has improved since my arrival (my position had been unfilled for…years…so they were without clinical supervisor support). I am trying to address this in other ways – although I’m not thrilled about a long summer vacation, I regularly encourage Grover to use annual leave, be generous with sick leave requests to account for travel time, support their attendance in training opportunities they are excited about, etc.

        I really appreciate your observation about how not approving the leave would help with burnout, because you’re totally right that it wouldn’t. I think it’s a reflection of me feeling stuck, but that doesn’t mean I should do things that aren’t workable!

        1. umami*

          I am so glad you are recalibrating on this item! My spouse actually ended up essentially quitting one agency he was working for right before our 2-week vacation last year (honeymoon that had been postposed due to COVID, we had never taken a 2-week vacation before). He was so burnt out working through COVID and feeling unappreciated, and then they were giving him grief for taking time off even though he is PRN, and the last time he had taken a few days off all his visits ended up as missed visits, so he was also feeling guilt at leaving his patients. And even though he struggles, he ALWAYS completed his documentation during the billing period even though a lot of others do not. So when he got back he just limited his availability to … unavailable. He did go back about 6 months later, and it’s been better, but he’s been much clearer about his boundaries. I know that’s not really the same situation you have, but taking away a vacation, or even creating a sense of guilt that makes the vacation unenjoyable, is likely to hinder progress with Grover rather than help.

          1. allathian*

            Yes, this. Although to be fair, if Grover’s truly burned out, a 2-week vacation is unlikely to fix things although it’s obviously better than nothing.

            When I had burnout following an intense project that nearly doubled my workload for about 3 months, I took 2 months off as sick leave + comp time + vacation. I’m not in the US, I’m salaried but we keep track of working hours, partly to ensure adequate resources. It failed this time because everyone significantly underestimated the workload of a project that had a statutory deadline, so I worked 50+ hour weeks when I typically work 37 hours. I took 2 weeks off just on comp time.

  69. Another Academic Librarian too*

    A clerical human being scheduled to help clear the backlog is an answer then that person will be scheduled to wrangle Grover to keep things current.
    Think of it as an accommodation.

  70. teaandcookies*

    I feel for everyone here. You should not have to put in this much work to get the documentation you need. Grover would ideally have a job that plays to their strengths and doesn’t leave dreaded tasks looming over them.
    As a thought exercise, what would you do if you knew Grover /couldn’t/ do these notes, or could only do 50% of them on a given day? If your pool of hireable people who can do the work you need doesn’t include someone with both the doctor skills and the documentation ability, maybe you do need to hire someone else (a scribe as others described it?) to do the other part. Yes there are strategies Grover can use and ways you can continue to enforce this, but it sounds miserable for both of you.

    1. OP*

      Hi! Your second sentence is so validating, and I love this question: what would I do if this wasn’t “solvable” from my perspective? Great food for thought.

    2. CommanderBanana*

      At what point is this job just…not a good fit for Grover, and won’t ever be? The documentation part is of this job is always going to be there and is intrinsic to the job itself.

      1. Llama Identity Thief*

        I think such a huge part of what’s coming up though, is that simultaneously the job is not a great fit for Grover, AND he’s a better fit than pretty much any candidate they could get to replace him, even if they could get one. The medical shortage is real, especially in rural areas.

        1. OP*

          Thank you for seeing this. I suspect anxiety also prevents Grover from job-searching, with is another element that leads me to feel for them, especially because there are less stressful telehealth jobs they could probably have!

        2. CommanderBanana*

          I understand the medical shortage in rural areas (it’s an issue my last org worked on) and I don’t doubt the OP when they say there are no other candidates.

  71. ADHDNP All letters all the time*

    As an NP with ADHD who struggles so much to keep notes under control… things that I’d want OP and Grover to consider:

    Is it the note-taking, or the billing side that delays the note being done? I know mine are often finished except for the final coding portion, and I never feel like I quite know what I’m doing for that part so I put off signing the thing.

    Similarly, are there particular types of notes that get put off consistently? For me, a Medicare Well Visit is a lot more of a headache than, say, a same day visit for a URI. If there are a few top contenders, TEMPLATE THE HECK OUT OF THEM. Use Grover’s previous notes for this type of visit to make the templates. Do not ask Grover to make the templates.

    And how much of what Grover is spending their time on is actually work that Grover needs to be doing? Are they making copies of handouts for the patient? Teaching them how to use a device that nurses could be teaching them? Helping them find a specialist who takes their insurance? All of these things can come up in a visit and feel like a “now” item, and delegating can free up a lot of time.

    I’m right there with Grover… (thankfully, not currently behind! but it’s a daily struggle…)

  72. ADHD'er in the house*

    Some of you might be underestimating ADHD, it can be pretty serious and rise to the level of disability. As a person I with ADHD I can 100% relate to the description of Grover’s problems.
    Depending on Grover’s precise situation it might rise to the level of needing accommodation.
    One concept I think could help would be trying “body doubling”. It is simply doing your own task next to someone doing a similar one. Most people subconsciously pick up on other peoples moods, but it can be especially helpful for people with ADHD.
    The youtuber “how to ADHD” has a video on accommodating ADHD in the workplace.

  73. UK Dentist*

    Can Grover use templates? I’d guess there is a lot of repetition in what needs recording for each encounter, so maybe a template which allows for the framework to be there and reduce some of the planning required.

    For example, I have something like this for a child who comes with toothache:
    Attended with:
    Medical history:
    Exam findings: (could be broken down further if always follows the same format)
    Treatment options:
    Treatment plan:
    Treatment provided today:
    Plan for next visit:

    Depending on software, some of these could even be set up as drop down boxes.

    Personally I find this makes keeping my own notes up to date easier, as I can just fill out the important information without having to look at a blank page. I have seen my GP use similar for routines such as asthma reviews.

    Which reminds me, my GP always writes his notes before I leave the room and tells me as he writes what he is putting down so I can make sure I agree. Perhaps this would be a technique Grover could try.

    1. OP*

      This is buried above, but yes, templates are already in use. Grover has trouble with the part that is typically several sentences of narrative in our field, but there were some good suggestions about with how to streamline further.

  74. Snarky McSnarkerson*

    what about a speech to text interface? then it’s a toy that they can teach.

  75. bamcheeks*

    As someone who *probably* doesn’t have ADHD but who often finds advice for ADHD useful, I am shouting, “YES, that’s brilliant, I should definitely do that!” at so many things here. :)

  76. Lola*

    Therapist here – I don’t know a single clinician who hasn’t struggled with the amount of paperwork and notes at some point in their career.

    A scribe or dictation is an okay idea, except for the fact that a lot of time in writing notes these days is not the content itself, but the logistics of an electronic medical record system. It’s convenient, yes, but it also invovles a lot of clicking through screens and checking boxes, something that usually has to be done by the clinician. Transcribing only gets the job partially done.

    My best advice from my own experience is mandating time every week, or maybe every day, when Grover has to do notes. Can their last appointment of the day be removed from their schedule for now to devote to note time? I do mine on Friday afternoon, but it seems like Grover might need every day.

  77. CityMouse*

    I know OP has said a scribe won’t work but I will say it was absolutely life changing for my Dad. He was up dictating until midnight sometimes until he got a scribe.

  78. IRelateToThis*

    First time commenting. I’m going to have to bookmark all of the tips. I feel for Grover bc I’m the exact same way with my extremely similar job. I’m excellent with clients but have the same struggles when completing notes on time. Anxiety, procrastination and chronic illness. My bosses are fantastic and work with me. It helped my anxiety to reframe. Being told “you’re not making mistakes. Your notes are excellent, when you do them” helped. The repetition of notes not being some insurmountable task, helped. I still struggle but I have been doing well for months. I hope the best for OP and Grover. And now to do my notes from my last client.

    1. OP*

      Yay for you! Thanks for the encouragement, and keep up the good work you’re doing.

      1. IRelateToThis*

        Thank you so much. I really appreciate your compassion with Grover. I hope they get the backlog taken care of and keep up with getting them done on time. You are in a tough situation and handling it well in my opinion. I hope Alison’s advice and the comments help. I do appreciate you writing in. Helped remind me to get my notes done on time for the week.

      2. IRelateToThis*

        Oh, I wanted to add: I have a recording of my supervisor stating my notes are good and just to start writing. I can listen to it to combat the voice in my head telling me I don’t write them well enough and the anxiety of writing them perfectly. It helps me to just start writing. Once I start, I’m fine. It sounded similar with Grover.

  79. Coverage Associate*

    So I hate entering my time, and it has caused lots of anxiety in my career. First, why has it caused anxiety? Because it’s only ever brought up in a negative context. I made a mistake, or the client is being picky. I am never rewarded for the thousands of entries that go good.

    What’s the fix for the anxiety? It didn’t really work for me, but a billing coach at my firm says that bills are client communication, same as reports and phone calls. Maybe remind Grover that notes aren’t just the worst part of patient care, but a part of communicating with colleagues? Or any part of the job they enjoy.

  80. squeakrad*

    Does Grover see the same types of patients on a regular basis? Are there catchphrases he could just use to plug-in, cut and paste type phrases that would at least serve as some reminder of what the next clinician would need to do if there’s an issue?

    I’m thinking of the academic software that I use for I can develop phrases and create them that I can use to cut and paste in my notes to students. Something like “your subject verb agreement is a problem in the sentence.” Are there specific phrases that Grover could use that he could just use again and again?

  81. Sue*

    It seems the focus in the comments is on their ability to write the notes. Tell me how accurate the notes can be with these types of backlog!!. This isssue is the patients safety 1st and foremost not trying to figure out how to adjust to this employees lack of adhering to necessary standards. I would fire this individual sooner rather than later. Your institution could be severely fined and/or punished for their noncompliance.

    1. SB*

      I am unsure where they are located but where I am, if the notes are subpoenaed by the coroner or by a court in a potential malpractice case the practitioner & the clinic can not only be fined, but cancellation of registration & prison are potential outcomes for incorrect or missing notes.

      1. CathyA*

        I’m glad someone else mentioned this. I was on a jury for a malpractice case against a physical therapy practice, and I can tell you that the failure to enter notes in a timely fashion was a very big issue in the case that ended up costing them a whole lot of money. When you are writing notes two to four weeks after treatment, it’s just very hard to believe that the practicioner’s memory was accurate. (Probably the award in our case was paid by their insurance, but still.)

        I don’t see how you can afford to keep Grover on staff when their behavior poses this kind of risk to your business. If you get shut down you can’t treat anybody, and that’s a lot worse than losing one provider now.

  82. Adereterial*

    I have a staff member who was chronically behind on admin work – mostly meeting minutes, notes etc. They also have an ADHD diagnosis and struggle with the blank screen.

    We pay for digital dictation and transcription software – Dragon Dictate. It’s minimal cost – less than £150 a year. They speak their notes, it transcribes, they proofread and edit where necessary and it’s done.

    To be clear – this sort of adjustment is a mandatory requirement in the UK to comply with the Equality Act, but even if it weren’t, the tiny cost should make this sort of thing worth a shot anyway.

  83. Coverage Associate*

    What solved the procrastination? My current firm reports attorneys behind on entering time to the highest level of management, weekly. Time for the previous work week is due Tuesday night of the following week. So there’s a grace period, but it isn’t so big that I get very behind.

    I would love a firm that had any reward for entering notes on time, rather than the sticks everyone uses. It would not have to be expensive. Just a $10 gift certificate for the lawyer most on top of this each month. Just something within the firm to make entering notes potentially positive, instead of only being mentioned when there’s a problem.

  84. Anonymous for discussing massive flaws*

    Oh, OP. From another Grover in the same field – thank you for understanding that this isn’t some sort of intentional petulant misbehavior. It sucks. It sucks for Grover, it sucks for you, it sucks for clients who deserve to have timely documentation, it sucks for cash flow, it sucks. I am absolutely a Grover and it has harmed me, my career, probably my clients.

    In my case (I am not rural but I work with folks who have a very specific vulnerability) I have also used my white hot rage to help. For example, folks with the specific vulnerability my clients have are often treated poorly and like their time and autonomy and humanity do not matter. Their rights are regularly trampled. This enrages me, as I entered this field due to its overt support for vulnerable people and for respecting the humanity of all humans. And so when I catch myself slipping on documentation, one of the things I tell myself that really resonates is “You were just yesterday losing sleep over how bad (some other provider or authority figure) treats your client because they know nobody cares about (population), are you really going to sit here and neglect their file like it’s no big deal? Isn’t that just the thing you were steaming about?” And that helps a lot. Maybe it’s not super HEALTHY, but it’s super HELPFUL.

    1. OP*

      This would totally work for me – but how do you do it without shame spiraling yourself, if that makes sense? Equity/access is huge for Grover, and we do talk about it, so I’m curious to if there’s anything specific you do to have this be motivating, not demoralizing!

      1. Anonymous for discussing massive flaws*

        I use a framing of living in congruence with my own values to avoid shame! It has been really helpful. I can also get reallllyyyy shamey and mean to myself. But I use a lot of self talk about my values and living in congruence with them – a positive framing of “you value justice and equity and the inherent dignity of humanity – what goes into living that today? does Bernie’s re-assessment need to be done? Do you have reports to (adjacent agencies) Belinda needs? What do the folks you serve need and how can you provide it?” gets the job done for me without triggering massive shame.

  85. Aiani*

    Maybe Grover could talk to a doctor or therapist about this problem. I had a stroke last year and it affected my ability to change tasks and focus. Practice with a speech therapist has really helped me to address this and she gave me recommendations of useful tools to help deal with these problems ( keeping a planner/journal, setting timers) I have found for myself that once a specific task becomes a part of my daily routine I will keep up with it so when adding a task to my routine I will write it into my journal/to-do list for about a week and then it becomes a task that I think to do automatically as part of my routine.

  86. SB*

    I come from a nursing background & not completing documentation is a serious offence in my state. Not only can you be fired, you can have your registration cancelled, which means you can no longer provide care to patients. This is across all clinical positions; nurses, OTs, physio, speechies, doctors, chiro, midwives, etc.

    I also have ADHD, depression, anxiety & my GP is pressuring me to get tested for ASD, so I understand how difficult it can be to get that boring AF documentation completed every single shift. The work around I set for myself was that I was not allowed to leave until that documentation was complete, even if that meant staying an additional hour or more (unpaid) to get it done. I soon learned to allocate time within my paid hours to complete the necessary documentation & stop procrastinating because I did not enjoy using my off time to do work tasks!

  87. Lizzy B*

    As someone who cannot get my ritalin Rx filled due to national shortages, I really feel for Grover and the daily acts of sheer will required to focus and perform when every single milisecond contains multitudes of distractions. (Not diagnosing from afar! Not disregarding the real impact on patient care! Just empathizing with another employee struggling against their own brain to do a good job.)
    When Allison suggested a variety of approaches that might empower Grover to be part of the solution, I was very hopeful the LW would find one of those effective. For example, I have been very surprised to learn lately that my most productive hours are between 4-11pm. That can be a problem for some workplaces, but not others… and if a low/no cost experiment with a solution from Grover proves helpful for the LW’s, it may be worth a try.
    Also as someone with multiple, overlapping medical issues, up to date notes on my care are crucial, and I salute the different pressures the LW is striving to address to make sure patient care is centered in any solution.
    Wishing LW all the best, and hope to hear what was tried/learned.

  88. 15 Pieces of Flair*

    Since scribes aren’t an option this may also be a no, but would it be possible to assign an intern or clinical student to Grover? Even if the practitioner needs to enter the notes, the student could draft the documentation for Grover and prompt them to review the draft after every appointment. This would remove the executive function barrier for drafting the notes and provide an accountability mechanism.

  89. Shelly*

    Is this a problem with only you as the manager? Is there someone else who could manage them that might be more in sync with how they work?
    I work with a lot of managers and some just put me on edge even though technically they do a good job.

    Also maybe instead of documentation after every session have random cram sessions where they catch up by staying late. Check in to see if this idea works. Don’t tell them the day just say hey we’re doing documentation today right before working on documentation.

    1. OP*

      It could totally be me! I actively solicit feedback, and my perception plus what Grover has said is that we have a good working relationship, but unfortunately we’re a small enough clinic that we’re stuck with each other. Never hurts to keep checking in about it, though.

      1. Shelly*

        Yes, after reading the other comments that makes sense. Also you may see if they have sensory issues…if it’s too bright, too loud, too quiet etc.

  90. Kristina*

    Can they voice record notes, that can be turned into a text automatically? like some sort of a program must exist for this – for example for people who are poor sighted
    maybe it’s the writing part that’s daunting

  91. Tute83*

    A few things come to mind-
    — the OP said that Grover’s ADHD is self-diagnosed. Why can’t it be diagnosed? It may not even be ADHD.
    — if it is diagnosed, then ADA may come into play. A clear disability determination could allow additional resources to be brought to bear to help them out.
    — are the expectations realistic? Can Grover realistically see all their patients in a given day and complete the documentation in a reasonable time?

    TBH, I’m not comfortable with a punitive approach to their problem. All an employer can expect from an employee is their best effort under the circumstances. And what about the other caregivers? Are they completing their work on time? Are they doing something Grover is not and might be able to teach them?

    1. OP*

      Just a quick clarification from something you may have misread – the ADHD and anxiety are self-disclosed, but are official diagnoses that Grover has received. I appreciate your & others’ suggestions to consider whether Grover should be using ADA, and will encourage their self-advocacy in that area. Regarding expectations, I wrote some additional context above you might find helpful – the expectations are not outside the norm for our field, and I meet them myself, so that’s not the primary issue.

      1. anonagain*

        Remember that employees don’t need to cite the ADA or use the term reasonable accommodation to make an accommodation request (if you are covered by the ADA). I think the Job Accommodation Network is a good resource here.

    2. owl*

      “All an employer can expect from an employee is their best effort under the circumstances.”

      Not really true. An employee putting forth their best effort still might not be performing at the level needed and an employer is within their rights (ethical, legal) to dismiss them for that.

  92. Delphine*

    Someone like this worked at my company. We had two PIPs for him and every one of his coworkers bent over backward to try and help him. Nothing worked. At some point you have to accept that some jobs are not a good fit for some people.

  93. The OG Sleepless*

    Ohh, medical notes. Grover needs to embrace the power of templates and macros. They are game changers. I have an enormous library of templates for exam findings, treatment plans, and so forth. They just have to be tweaked for the individual case and dropped straight into the record.

  94. Avery*

    Disclaimer that this isn’t actionable for OP (unless it’s offered as a friendly suggestion, but it’s not really managerial material), but it would be actionable for Grover, and for my fellow Grovers with ADHD reading this and feeling seen and looking for solutions:
    One thing that’s really helped me is those apps you find that turn everyday, mundane goals you set into fantastical, game-like achievements. Habitica, Finch, I know there’s others out there… And keep the goals small in terms of both time and achievement! “Get through all the backlog by this summer” likely won’t be a very helpful goal, but something like “do two notes from the backlog by Wednesday” or “do all the notes for today’s sessions by the end of the day” can make a big difference.
    Different field, different context, but this is helping me noticeably with motivating me to get billable hours in while working from home in the legal field–both the use of the app itself, and the subdividing of goals to keep them small and easy.
    My initial goal was the full amount of billable hours I was supposed to be doing every day, but it was easy to look at that and go “oh, I’m so behind, I won’t get there, why even bother”. Now I set individual goals for each billable hour of work, and it’s a lot easier to get myself to do more work when I can go “oh, well if I just work 20 more minutes I’ll be able to unlock this next goal, I’m already so close-“

  95. Down with DV*

    Grover could just die at any time, I have never understood putting all the critical eggs in one basket. All you can do is temporarily reduce services without him, however he leaves. That’s isn’t the best situation, but what else can you do? I would rather have a good clinician than a good documenter, as a patient. But yeah, you’ll have to be more heavy handed about getting the paperwork done since it’s important a big backlog not build up, and Alison’s suggestions are spot on. That said, someone without these issues may be a better match for the position, clinical skills notwithstanding. Perhaps Grover would be happier doing something else also. Critical job functions can’t be barely done because of ADHD. Good luck.

  96. Alyssa*

    As a provider myself also working in an underserved population I have to ask if there is more to this persons inability to complete documentation? How many patients do they treat per day? Many of us struggle to complete our documentation simply due to an unreasonable and unsustainable workload. Sounds like this could also be the case if positions are empty. Maybe rather than cracking down on this provider and fear forcing more documentation you should re evaluate if they have an appropriate amount of work to begin with?

  97. WS*

    I work in rural healthcare and we had a GP who was an excellent clinician but had the same problem with notes. We’d just gone three years with no regular GP in town so *anyone* would have been an improvement, but this doctor was great…apart from the notes. It wasn’t a financial issue in our case but it absolutely was a clinical and legal issue.

    The eventual solution was hiring a retired nurse to basically sit with him and input the notes on his verbal instructions. She was still registered, and still wanted to work, but couldn’t physically cope with the heavy demands of a nursing job anymore. Patients loved having her there because she also helped them with the admin side of their healthcare. Staff loved having her there because they could talk to our Grover about actual clinical issues rather than “where are the notes?”

  98. anondoc*

    As a physician who has struggled with charting I took a phenomenal online physician coaching course – Charting Conquered- it focused on not just templates and macros but the mindset and hang ups many of us have around perfectionism and imposterism and ideas that a note “should be” a certain way to be good. Working through these issues was transformative. I don’t know if this exists for your profession but might be something to look into.

  99. Mjones*

    I also work in rural Healthcare. It is written in my providers’ contracts that they will finish documentation within 72 hours or they will get docked pay. Look at his contract. Maybe something is written in their about it.
    Do they have a dictation device so they don’t have to type everything? Are they seeing too many patients? Maybe there are shortcuts and canned text that can be set up in the EMR to make documenting quicker. Babysit them while they complete documentation. Sucky situation either way.

  100. MS*

    I am a disability rights lawyer and I want to reframe some things for OP. If you ask a corporate type lawyer they’ll tell you you can fire Grover because they can’t do all the parts of their job. But I want to explain why that’s legally wrong but also ethically wrong and a bad business decision.

    ADHD is a condition that actually can really enable people to excel in medical professions. ADHDers can have a great ability to recall all types of facts, synthesize information in complex ways that neurotypical people do not, great at handling crises, and deep empathy, to name a few. All of this can make them excellent diagnosticians, excellent with patient treatment, and more. The type of clinician you are lucky to have willing to work for you. But ADHD makes it difficult for ADHDers to complete admin tasks, and/or difficult quickly pivot between patient treatment and billing and back again. It’s a difficulty ADHD health care workers, lawyers, and lots of other skilled professionals with time billing/admin involved face. But here’s the thing- the skills of billing time don’t necessarily make you a better health care provider (or lawyer etc etc). (Also- Sometimes the best billers are the ones who are less good at the substance of their work, they’re just good at documenting stuff. Obviously not true in all cases). So the real question is- is Grover good at treating patients? If so, make the rest of it work. Because you can. And because skills like “good at treating patients” is a harder skill to find that “types notes.” And patient care continuity matters. What do you want to say to the patient who is upset that Grover is gone? “I’m sorry I know they were an awesome provider but they got behind in typing up after visit notes and we decided that rather than help we would terminate them. You’re new provider isn’t as good, but golly their secretarial skills are better.” Think of it like you’ve hired a great chef whose not good at washing dishes while cooking bc then the soufflé burns. You’ve tried, but they just can’t do both well. What you should do is hire a dish washer, or buy a dishwasher, because all of that is easier and makes more sense than finding a comparably good chef. Do this, and the chef will make lots of tasty dishes and your restaurant will thrive, don’t get bogged down in whether other chefs need this too.

    So with this mentality, what do you do for Grover?
    1. You sit Grover down and say you’ve been approaching this wrong, you love how good they are with patients, you don’t want to lose them and you want to find a way to assist them with the admin tasks they struggle with so that they can focus on the patient care they excel at.
    2. You ask what THEY think would help. Take it seriously.
    3. If they don’t know, offer scribe / assistant options and to pay for a few sessions with an ADHD coach to help figure out solutions.

    As a bonus point, if you find a way to make it work, maybe Grover can see more patients, or do other things they excel at, like training staff, patient outreach, maybe something else you and/or they identify. A wise person I know once said (separate from ADA issues) that good managers find out what you’re good at, and try and take away the chaff bogging you down so you can excel at the things you’re good at. Mediocre managers don’t differentiate, and apply the same cookie cutter standards, and bad managers fixate on your weaknesses, yet won’t acknowledge your strengths. Be the good manager to Grover.

    In regards to the legal ADHD issues, remember that the question of how much must you pay for an accommodation is judged proportional to the entire organization’s finances, not just your division or Grover’s salary. I haven’t seen anything from OP that would explain why a scribe isn’t a viable ADA accommodation. We haven’t done it isn’t a basis. There are lots of ways to do this (in person, remote, other admin staff asked to assist a bit). Also, recently a jury awarded 200k in a case where a hospital denied a medical scribe to a physician who needed one.

    Make it all work. You can do it.

    As a bonus point, here is a lawyer speaking about some of these issues in the legal profession that might be helpful to you:

    1. Someone who's been there*

      Yes to all of this. Alison usually writes wonderful headlines, but the headline for this one, which is “how do I manage a bad employee I can’t fire?,” isn’t the best summary of the central premise. It’s not clear to me that Grover is a bad employee. Maybe they are, but maybe they are just being put in an unworkable situation that has a whiff of, “Neurotypical people aren’t having a problem, so why are you?”

    2. allathian*

      It seems to me that many employers are shooting themselves in the foot by requiring expensive subject matter experts to do admin tasks that someone else could do for a lower salary instead.

  101. Qwerty*

    Late to the party but I have two thoughts:

    1. My neurologist writes most of her notes during my visits. She jots down some stuff in the system while we talk or as she learns something during an exam. Then the last 3 minutes she types at the computer and sometimes asks me a clarifying question ( would you say the migraines are more X or Y?) and ends by telling me a summary of our visit and my aftercare info to make sure we are on the same page. Would something like this help Grover? That way the notes are in rough draft mode by the end of the patient visit and they only need to clean/polish up the notes during the break between patients

    2. You mention in the comments that Grover has been doing a decent job recently of staying on top of the new patient notes but is struggling to clean up the backlog. Would it be possible to reduce patient load in the short term to give Grover dedicated backlog clean-up time? Something like use the first patient slot of the day to write 5 backlog notes or take 2-3 days and just do backlog notes? I figure first patient slot is the best time of day because otherwise they might spend the time on that day’s patients. If someone is struggling to stay on top of their daily patient load, I can imagine it must be that much harder to do the daily load + backlog cleanup. (Not saying it fair to take away appointment slots, but trying to work within the parameters of not replacing Grover at this time, plus you need those notes covered before Grover leaves or is let go)

  102. Lasuna*

    I strongly recommend what Healthcare Manager said about stopping providing positive feedback on Grover’s notes. It sounds like you have been doing it long enough that if it was going to help, it would have already helped. It could actually be reinforcing Grover’s anxiety without either of you realizing it. For context, I used to work in a residential mental health facility. A subset of my patients found positive feedback of this kind to make their anxiety worse long term, instead of reinforcing whatever behavior they got positive feedback on. One way of understanding this is to recognize that you probably don’t give the same level of positive feedback to other clinicians about their notes. You provide it to Grover *because they are anxious.* If it is important to Grover to get that positive feedback, they need to continue to be anxious. I’m not saying it is manipulation – if this is what is happening, Grover is probably unaware of it. I’m just saying that human brains are weird, and sometimes reinforcement doesn’t reinforce what we intend.

    Instead of providing positive feedback, make Grover provide it for themself. In situations where you would usually provide feedback, ask Grover if they are happy with the way the note is written. Ask what they think they did well. Getting them to praise their own notes may be effective at getting them to internalize that they can do a good job.

    I know Alison already clarified that withholding pay would not be legal, but I’m going to chime in on that to say that even if you could do it, it would not work. I currently work for a home health agency, and all of our clinicians who see patients are contractors. They are paid per visit and have to provide proof of visit (i.e. notes) in order to be paid. Many of our clinicians are still terrible about completing their notes. Our worst offender will only turn in notes when her supervisor calls her and tells her he is going to continue to call every half hour until the notes are turned in. The fact that she won’t be paid apparently does not matter more than whatever gets in the way of doing the notes. I imagine it would be similar for Grover. They’d probably make sure to do enough notes to pay their mortgage, but I think generally the immediate crisis of their anxiety/ADHD will matter more to them than future money/vacation/other incentives. I understand wanting the answer to be as easy as treating Grover like a rational actor who would make better choices with the right information/incentives, but if Grover were going to behave like a rational actor you would not have needed to write in.

  103. I am Grover too*

    I was Grover in every way for a very long time. I’m going to give a bunch of things that helped but by far, the biggest one was a shift in the thinking that I was supposed to overbook patients and run around ragged all day long because we were short-staffed/the area has a deficit of providers in my field/the community needs me to see all these people/others can do it, why can’t you/etc, and then I was supposed to look at a mountain of charts after clinic was over and finish them after hours, when I was already hungry and exhausted. And I didn’t get a productivity bonus, so seeing more patients did nothing for me financially. If Grover is already burned out, then I would suggest really considering whether it would be okay if he saw X fewer patients each session so they could write their notes in real time. You may think they’re inefficient/goofing off if they aren’t super efficient during the clinic hours, but they may just be exhausted and need a break rather than running to the next patient. Or they just aren’t as fast as you are, but well within the typical range — which is okay and not something they necessarily have to justify.

    Without changing the conditions that led to my constant exhaustion, I don’t think any of the other things I’m about to mention would have worked for me. But they helped once that premise got changed.
    – I incorporated writing the note into the visit. I started writing the note before I entered the patient’s room (which also made the visit with the pt much more efficient because I knew what I was looking for), reviewing their questionnaire and old records. Sometimes I would do this in front of the patient at the beginning of the visit, saying to the patient, “I need to review your old records,” so they would see how much time I was taking on their behalf rather than thinking I spent ten minutes total on their care because that’s all the time they saw me for now that I was more efficient.
    – I would not go on to the next patient until I had written everything up to the impression and plan so I would not forget anything and then write bullet points on the plan so I wouldn’t forget anything. Ideally, I would write the entire note if it was straightforward before starting the next visit.
    – The electronic medical record system we use allows you to write your own “smartphrases,” which are small macros – you type a short phrase and a paragraph comes back. I have literally hundreds of them now, because the same things come up on different patients, and if I’ve spent that much time agonizing about the wording, I might as well make a smartphrase out of it so I can retrieve it later.
    – Every provider gets a list of all their charts that are open for more than a week after the visit. (just their own, not other people’s.) This didn’t help when I had hundreds, but now that it’s single digits at the worst, it’s nice to not get the list at all because every chart is closed. It’s a little bit of a game to get the charts closed the day before the list comes out! An artificial but immediate deadline will help more than a threat about July.
    – After clinic is over, after a brief break, I use the Pomodoro method and set a timer for 25 minutes and tell myself I’m not doing anything else for those 25 minutes until the charts are done. And usually they are done well before the 25 minutes are up. If you are able to, just designate the last slot in the schedule as “clinic wrapup” or something like that, so Grover and everyone else is of the mindset that clinic isn’t actually over because the last patient is gone, it’s still going on but now it shifts to documentation/review of phone calls/test result review/etc. And I think it also reinforces the recognition by the employer that the provider is still working on their behalf, that clinic is not over for them just because the patient is gone.
    – Does he bill under Medicare or comparable insurance? Medicare reimbursement policies changed in 2021 where you could now get credit for the time you are writing your note, but ONLY if you are doing it on the same calendar day as the visit. Even though I didn’t personally see the extra money from billing at a higher level, it seemed silly to have the clinic get less money because I didn’t finish my charts that same calendar day but waited until the next day.
    – For the backlog, it may be worthwhile to cancel a clinic entirely (or half a clinic, twice) and tell them that they are coming to work and rather than see patients, they are getting rid of the backlog. They (and you) will feel a thousand times better after the backlog is gone, and they may be able to keep it from re-accumulating once that oppressive and seemingly insurmountable mountain is gone. That backlog is hanging over their head and making them feel defeatist in a way you may not realize.

  104. LH*

    ADHD pov, with considerable experience managing others with ADHD. This may have been posted already, but… ADHD. I couldn’t get through all of them :) I see two potential areas here. 1) Needing a deadline rather than just vagueness. Absolutely Grover may get everything done – at the very last minute before that trip deadline. Long term possibility may be deadline of x number of notes per day/week (depending on case load), with a follow up or some other negative feeling consequence to really feel like a deadline. 2) Overwhelmed by the numbers. I get overwhelmed when I have a large number of things I have to do, so breaking it down is necessary, without distraction of constantly talking both the long term and short term goals. A way around this, for the backlog, is to say, here is today’s/this week’s goal. and leave it at that. Beyond the initial conversation, don’t mention the rest of the backlog. At first, you may have to say with “start with this category/date/etc.”, again to not be overwhelmed with where to start.

  105. Silverose*

    This was me when I did CPS assessments and my county was vastly short staffed…or when I was a wraparound facilitator with too large of a caseload and the way we were required to manage our documentation didn’t work with how my brain works, on top of developing chronic health issues.

    Key phrasing: what accommodations do you need for this disability to get through the backlog while still keeping up with current documentation?

    If neither you nor your employee can think of accommodations that might help, look at the Job Accommodation Network website. They have a lot of suggestions based on symptoms experienced.

    Not getting their vacation for what sounds an awful lot like burnout on top of mental health challenges is only likely to demoralize your staff member…and/or lead to a mandatory stress-related medical leave of absence. Ask me how I know.

  106. Fellow Supervisor*

    Is this a situation where Grover is working under your license (like on a state-mandated contract where you’re their supervisor of record, they have to do x amount of hours of clinical work and get x hours of supervision), or are they independently licensed and this is solely a Grover/HR issue?

    If it’s the former, you gave a BIG problem, because you’re legally responsible for their cases, but either way, it’s still an egregious problem. I also provide clinical supervision, and I have a really hard and fast rule that if someone gets more than 7 days behind on documentation, they can’t see clients until they’re caught up. Is it yucky client-care wise this way? Yes and no. Yes because it could pose a problem if a person isn’t permitted to do direct work (which could interfere with productivity requirements if your agency has them)…But also no, because I find that the clinicians at my practice REALLY do not want to have to cancel in general, never mind because of documentation – it feels like sh*t to have to do that. But all of that is theirs to manage and if it comes to that point, if I have a supervisee who gets that behind and I hold the boundary, they somehow miraculously get caught up.

    That said, I’d put this MUCH more on Grover than it sounds like you might be. I’m also making a (potentially wild) leap that we work in similar healthcare fields, and we can sometimes have the impulse to rescue, especially when we know that someone who works for us is struggling, but let the consequences be Grover’s. I’d also argue that it’s a bigger risk if they become too impaired to practice and have to leave abruptly and are that behind.

    (Then again, I also lost my conscience long ago about documentation. It’s a hugely important part of client care and if they’re not getting it done, it’s potentially a symptom of a much bigger problem.)

    1. OP*

      Hi! Your leap is not wild :) Grover is independently licensed, and it sounds like you and I are similar. I would not tolerate the late documentation under my own license. It’s just not good care, and although there aren’t other major issues, it’s connected to other, more minor issues. I really value the reminder about rescuing: a huge volume of comments are really helpful for Grover, but not necessarily for me, or for me to do anything other than suggest to Grover, and I’m confident that I have consistently been encouraging them to identify what would help them. And Grover will identify things! It’s the follow-through that is really the struggle.

  107. Rene*

    I’d really encourage coaching Grover on getting up to speed with concurrent documentation. It makes my 10 hour days as a counselor much more manageable. Aside from just documentation and billing, if they are that far behind on notes I can’t imagine they’re able to do other administrative tasks like referrals to medication providers or groups.

    My supervisor also pointed out that concurrent documentation means that if the therapist is ever called to testify, they can simply read their notes in court. Whereas if the note is done (much) later, it may cast doubt on accuracy or open the organization to liability.

    If typing is a barrier, I’ve taught several coworkers over the years how to use a handwriting input/alternative keyboard. You write as normal and the program converts that into typed text – and some can read both print and cursive. Just as autocorrect learns your common word choices, these programs learn your specific handwriting as you make corrections. This method can feel more comfortable for “old school” folks who are used to taking notes with pen and paper.

  108. Josh*

    Most Regulatory bodies for health care workers require timely documentation. Failure to do can cause actions against their license especially if something were to happen to a patient, it’s shown that it was a severe issues (ie 300+ notes pending), it has been addressed and still allowing to continue which shows a blatant disregard for the rules.
    Sometimes knowing that losing your job might not be the worst thing that can happen can help with perspective.
    Also thing about what would happen if Grover and the practice were to be sued.
    Damages would be greater for both the organization and Grover personally if they can show Grover was doing untimely reports showing a lack of professionalism and care about doing proper work. Especially if they show it was a issue known to management and had not been fixed.
    We’re short staffed so we let someone stay who wasn’t doing what they are supposed to is not a good legal defense.
    Untimely documentation has less veracity that timely documentation and may even be seen as a attempt at a coverup.
    Would your organization be able to remain afloat after a major lawsuit? Are you taking that into account when making your decision to not fire Grover?
    As for billing would having someone on staff to replace Grover increase revenues from getting timely payor submission such that you could offer a sign on bonus or similar to attract someone to replace him?
    Could the pay be restructured such that providers pay is based on part off of what their billings bring in such that not being able to submit his notes had a direct impact on his paycheck. This would be for all providers in the practice.
    Could their be a solid plan to place to not go home until all that days chart are done.
    Could he take like 2 or 3 days off from seeing patients to get caught up and then have a firm plan to not leave each day until finished.
    I know what’s it like to keep people because there’s no one to replace then but ultimately it usually turns out better to suck it up and get rid of it then to keep it around festering.

  109. Adelena*

    I have ADHD. For me it would really help to 1) get really strong incentinve to get the backlog eliminated (you got that) and 2) a plan starting the first day back to work that allows them to do the notes every single day. It HAS to be worked in to the day and it has to be concrete. How long does it take to make a day worth of notes and add that time to the end of every day (I would personally do this with a timer and good music). Or 5 min after every patient. It might seem like it’s “just not possible”, but if it’s a requirement of the job it just HAS to be possible. You have a good provider who needs this to do their best work. Ask them what would work for them but for the love of everything, don’t let them do it like once a week or something else overwhelming. Small and specific.

  110. I relate to Grover an uncomfortable amount*

    This is an interestingly timed letter, because I have been thinking of writing in to AAM as the Grover in this situation. Our circumstances have quite a few differences, but I am significantly underperforming, and I have been working with my boss on how to bring my output up to speed.

    One tip that might work for Grover (that doesn’t apply to my employment situation sadly, but I do apply it in other areas in my life) is: is there a ‘quick and dirty’ version of a note that Grover can produce right away, and then come back to later to spruce up? OP mentioned that they have time between appointments, but it might be difficult for them to initiate tasks so having a frequent but small window of time might not be ideal for them. Perhaps they could have a dedicated few hours of pure admin time once a week, or however often would be helpful here.

    Here’s an example of how I use a similar strategy in my personal life: I’m currently studying a language in an app, and if something noteworthy comes up that I want to revisit later (an unusual verb conjugation, a grammar nuance that I want to understand better, etc.), I take a screenshot, and then add a quick comment on the screenshot summarizing why I took it. If I stopped the lesson to fully address the issue, it would completely derail me and I’d never finish. But I can do that kind of quick and dirty prep that makes things way easier for me to come back to later and clean up.

  111. should decide on a name*

    I understand your frustration. I have ADHD and a background in healthcare, so perhaps my experience may be helpful.

    As a neurodivergent person, I can advise that a PIP has a very good chance of making Grover’s ADHD and anxiety symptoms worse. I absolutely loathe PIPs, because I have seen them abused and misused constantly, either as a power trip from a bad manager, or as a replacement for basic training, support, communication, and management.

    I would strongly advise that you look at accommodations and support, because not only does that set Grover up for success, it also allows you to keep someone who appears to be very good at the clinical care element of the role.

    My stepson works as a lawyer and, due to his ADHD and dyslexia, finds dictation extremely helpful; he will recite his client notes into voice-to-text software, alongside either a voice memo on his phone, or a handheld audio recorder. The voice-to-text software is pretty good, and it usually just needs checking for typos (sometimes against the backup audio recording). A lot of neurotypical people use a similar system. Perhaps this might be worth considering?

  112. Quinalla*

    You have gotten lots of other great advice. I saw that a scribe isn’t possible, that was going to be my suggestion of some way to hire someone, etc. to help take that admin burden off of your otherwise it sounds like good employee.

    What would help me in this situation is reframing in my head that the notes are not JUST for billing, but an important item to do to protect my patients if there is a crisis. Other medical professionals NEED those notes.

    This is what I’ve done with my own personal hurdle of getting timesheets done (UGH). It isn’t just so we can get paid (some of our time is billed hourly and other parts of it we don’t get bonuses until everyone has recorded as it can’t be calculated properly), but ALSO because fellow coworkers can’t do their jobs until I get this done. I’m holding them up which isn’t fair! It isn’t as much motivation as patient care (or client care in my case) would be to me, but it does help.

  113. ScribeRootingForYall*

    If you’re able to reconsider the issue of a scribe OP then I highly recommend it! There’s a ton of different options as far as remote/in person and a really good scribe can honestly knock through a ton of notes so fast

    I think there’s a lot of great suggestions above for strategies to help Grover going forward, but speaking from an ADHD perspective myself here I can’t imagine the executive dysfunction/anxiety whirlpool that backlog must be causing—if you’re able to help them get caught up with some extra help (even if only temporarily) I imagine that would really help in the long run

  114. Disabilities are not decisions*

    Something to remember here, for OP and everyone in the comments: This is a disability, not a decision. Sometimes disabilities look like decisions from the outside, but they are not. They are disabilities.

    Imagine you had an employee with a physical disability whose work was 80% sedentary, but required climbing a ladder 20% of the time. The nature of their physical disability means that they technically CAN climb the ladder: they are not wheelchair bound and have some motor control. But their hands and feet are numb and weak; they fall off of the ladder often; they get dizzy at the top; they wobble and sway and sweat the whole time they are on the ladder. Internally, they dread the moments they will have to climb and shudder at the sight of the ladder everyday.

    If that were true, would you look at this punitively? Would you put your disabled employee on a PIP because they are not great at climbing ladders? Would you think that–because they are capable of climbing, regardless of the effort it requires for them (especially when compared to others)–their disability wasn’t really “real”?

    I know that the ladder MUST be climbed in order for this job to function, but it seems crazy to me that many suggestions have been along the lines of “more punishments when they wobble!” or “tell them that they are swaying for no real reason!” or “take something important to them and put it at the top of the ladder, then they’ll have to climb it!”

    Is there no way to build a lift instead?

    1. OP*

      Thank you for keeping the focus here. You’ve helped me realize something I was totally tangled up in. I definitely am quite clear that Grover has a disability, and is not making decisions not to finish notes in a timely manner. I do think that a big part of where the issues have arisen between us is that neither Grover nor I are treating it like that, if that makes sense? There have been multiple times that I have offered things that would certainly be considered accommodations (like clearing their clinic schedule for however many days they think they’d need to work through their backlog), but Grover hasn’t taken me up on those, nor have they approached me with accommodations they think would be helpful (and so many people have suggested here are totally workable!). That’s what has me frustrated: we’ve identified an issue, I believe I’ve communicated that I’m open to whatever reasonable solutions would help, and while things have improved, there hasn’t been a procedural shift that would allow Grover to do the work. The good news, which I’m excited about, is I can revisit all of this with them. Not writing timely notes is ultimately a requirement of the job, and (staffing/recruiting issues notwithstanding) is likely to result in termination. BUT, let’s back the train up and really focus what accommodations would mean I’m no longer considering it. I realize that part of this is not mine to solve: Grover has to play an active role in imagining what success in this role would look like for them. I can certainly make clear that I’d happily respond to their self-advocacy, though! Thank you again.

      1. Disabilities are not decisions*

        Thank you for replying. All of this must take up a great deal of emotional and mental energy. I wonder if we could keep up the analogy for a moment to see if it helps clarify anything. (This is an exercise for me. I may delete it when I get to the end.)

        Let’s say your workplace is set up with ladders for accessing certain things. Like one of those old libraries with the book ladders that slide down the stacks. This ladder system was set up a long time ago, and it seems to work for most of the librarians. It has been added onto over the years; everyone talks about how many rungs it takes to get from A to Z, in a joking manner. Everyone agrees that ladders are sometimes unsafe and that they also struggle when they are temporarily disabled (say, with a sprained ankle or a broken wrist).

        You now have an employee with a chronic illness that affects their ability to climb ladders. In the past, this person probably wouldn’t have been able to become a librarian at all due to their illness, but some combination of medical technology and increased accessibility has opened this career to them. You agree that they are great at being a librarian, except for the ladder-climbing part.

        By asking your employee to create their own solutions, you have essentially asked them to be the architect of their own lift system. Now, this person is a great librarian, but they are not an engineer. They have never had to create a system like this from scratch, and it’s intimidating. Plus they’ve internalized the idea that if they just try hard enough, they could climb ladders like everyone else who works there. They’d have to stop everything they’re doing to turn their attention to lift-building, and they still might not be able to do it, because it’s a complex task.

        The thing is, if you build a lift system, EVERYONE who works there will benefit. The ones with the sprained ankles, and the ones who are carrying too many books at once, and the ones who use wheelchairs. My organization has both escalators and elevators to move people from one floor to another–because sometimes more than one solution is needed when there are many variables to consider.

        Since the library is already built, and both you and Grover just work there, this seems like a group assignment to me. Grover should absolutely play a role in this project, but I don’t know if it’s fair to place all the responsibility on them. And I think the assignment is not to build a hoist that just lifts Grover a few more inches to the top of the stacks after they’ve gotten exhausted from climbing, but to build an elevator that allows anyone to go from A to Z–with a whole cart of books AND a broken leg!–whenever they want to. But that may require redesigning the whole dang library, and not just dangling Grover from the rafters periodically.

        Now that I’m at the end, I don’t think I’ve helped because the task still seems very daunting. (But I decided not to delete the above because of the mental image of “dangling Grover from the rafters.”) I guess I’m asking “Can anything change about the structure of this system?” Everything seems to always come back to changing Grover.

  115. Timothy (TRiG)*

    Is this me?

    I work in web development, not health care, but for some reason logging time is the most difficult part of my job. I’ve found that doing it first thing in the morning does help a lot, but it’s still difficult and I definitely don’t log all my hours. And yes, I have made some small efforts to get an ADHD diagnosis.

  116. Cafe au Lait*

    Would it be possible to set Grover up with a notes template to utilize? For example, I, someone with ADHD and anxiety, needed to write several cover letters recently. What helped me was to have the cover letter template Alison recently published open on one half of my screen and my working letter on the other half. Obviously the template is cobbled together from several example letters, so I wasn’t copying. But I was using it as a tone check. I’d draft a paragraph and then refer back to the template to make sure my tone matched. If I got stuck I’d refer to the template to see how the writer transitioned from one idea to the other.

    Grover, along with your input, could make their own template.

    “Morticia Addams, 40 year old white female, presents with medical term, medical term, medical term…”

  117. Serious Silly Putty*

    Look up the “Wait But Why” web comic on procrastination; it may give you some insights into Grover’s brain?

    It sounds like notes has become the “Impossible Task”. It’s really hard to get out of that trench. For me, it’s not just because it feels overwhelming, it’s because there are so many layers of shame attached. I just need to reply to the email, but to answer the question I need to figure out the schedule, which I haven’t done because I suck, and because I’m horrible at confrontation, and because I didn’t send out the calendar request in a timely manner, so really it’s my by fault I’m in this situation, and — oof. It’s a lot.

    Here’s a few things that sometimes help me:

    – Set a tiny, easily doable goal for them, that needs to be done by tomorrow. (“I need to review Mrs. Jones’ file. Can you tell me what you did last time you saw her?”) Sometimes if my brain knows I only have to do something tiny, it doesn’t trigger the “flight” response that’s actually me avoiding the shame related to the big mess.

    – If it’s some version of writer’s block, accessing a different part of my brain can help. I once wrote a draft grad school paper in a series of haiku. Another time I wrote hilariously badly on purpose, to shake my need for wording things well. Perhaps something like “I think part of your struggle is your brain needs more stimulation than writing notes can provide. At the end of the day, I want a haiku for each of the day’s visits. From those I’ll prioritize which ones I need proper notes for first” (confession: I’ve never demanded this from someone else, it’s always been for myself.)

    – “Body doubling”: Working on a thing at the same time as someone else. Could you schedule a daily 30-minute zoom work session where you agree to stay on camera and work on your respective most tedious tasks? Or would there be a way you could process a claim in real time as they submit the note, then they could share in the “dopamine hit “ of it being done?

    Last thing: I mentioned shame above. You’re not Grover’s therapist, so it’s not your job to unpack all this, but it could be worth reminding them that being bad at a task is morally neutral. If they are blowing it off because they just don’t care and think they can get away with it, then that is disrespectful of you and their clients. But *struggling* does not make you a bad person; your struggles/failings can still cause real harm, and you should work to improve those areas, but you should not feel shame or guilt, only responsibility.

  118. Cycopath*

    I know you said that scribes aren’t an option for your setting, but I would like to know more about why. My thinking is simply that if Grover has an ADA qualifying disability in his ADHD, a scribe might be absolutely appropriate accommodation that might be required. I mean if the choice is letting him go, which you don’t want to do because the position will remain open for an eternity, or actually providing him accommodation under the ada, maybe a scribe is a possibility even though you initially ruled it out as an option. it might not be an option; you know your own circumstances best, but if it was legally required in order to accommodate his disability, perhaps you would find a way? or not. it may be impossible. only you know. but I thought I would raise the issue of this being a possible disability under the ada. Sorry, I haven’t read all the comments, so if someone already raised the Ada issue, I apologize for the duplication.

  119. Kimberlin W*

    Unfortunately I don’t have any advice, but I can empathize completely because we were in the same boat a year ago. Rural health care, systemic access issues, good provider, terrible backlog, broken promises. Care not being documented became a serious patient safety and continuity of care issue, and the provider’s employment contract was not renewed. Almost $100k services went unbilled because so many charts weren’t closed. (That was a hard one for the board to swallow). A year later, that position remains unfilled and access is even more affected. It’s heartbreaking. Best of luck to you, OP. I’m rooting for you!

  120. Aspiring Great Manager*

    This is a really hard situation OP! I totally sympathise and in a similar situation, I have micro-managed the hell out of people with varying results, one upped their game enough that I was able to stop, and another just quit in a ball of fire, very dramatic. Varying results but it can work if the person has the motivation, which sounds like Grover does. So things like: Grover must complete and email you the notes every day at the end of the day. If not done, then send them early in the morning before seeing the first client. Also, for the backlog, any change you can have Grover do notes for a day/an afternoon to catch up and then ‘start’ fresh with a new system?
    But, one thing I really plead with you is please please do not cancel their leave because of the notes. Cancelling people’s leave for anything other than real life-death things is Very Demoralising, and I would hazard that Grover’s performance will actually get worse if you cancel their leave because they will see that their efforts are for naught and will ‘love the will to live’ so to speak. Have Grover complete his notes before leave and let them enjoy their time. Leave is not a prize at a job, it is a requirement for rest and rejuvenation, Grover needs this regardless of the notes, and if things are going well, it will hopefully help you all turn a page.

    1. OP*

      Yeah, I can tell that I need to address my own frustration with this situation because I normally consider leave to be a right, not a privilege. That is harder to stay mindful of when someone’s not completing an important part of the job.

  121. Hexiv*

    Maybe this is a stupid question, but is it possible to hire an extra person to do the part of Grover’s work that they struggle with? Or at least to do the OP’s micromanaging for her? It sounds like her problem is that she can’t find /trained/ people to hire – so maybe she could hire another untrained person to keep Grover on task with this? A good note-taker is pretty valuable, but easier to find than a good physician.

  122. Hybrid Employee (Part Human, Part Wolf)*

    This is so far down I’m sure it’ll get missed, but, my experience managing employees with ADHD is that you’re dealing with a usually-manageable constellation of specific, structural issues. Grover isn’t not doing their documentation “because they have ADHD;” *something* about the process is unmanageable for them. If I were in your shoes I’d be looking for the barrier we can target.

    What I’ve found useful for adapting a process for ADHD employees:
    – Eliminate task-switching = Grover might have a hard time going between “do care” and “take notes.” What if Grover has to do all their documentation at once, at the end of the day when it’s their *only task,* and then turn it in?
    – Out of sight, out of mind = is Grover keeping their documentation notebook in the trunk of their car? Guess what, it has to be attached to their dashboard now.
    – No mental copy-and-paste function = asking them to hold a large amount of information in their head is a losing game. Any instructions they need to follow consistently need to be immediately accessible reference material, and also short enough that they don’t have to hunt through it. Example: I tore pages out of an instruction manual and taped them up to the wall instead. The employee who had been struggling with the process *quintupled* their speed on the task the day I did it.
    – Eliminate black holes = Anything that’s unknown becomes a gravity well where a person can get stuck. Is there any part of the documentation process that ISN’T punctuality where Grover’s work product has been shaky before? They may be struggling to execute the whole thing because they’re unsure how to do that part correctly and they can’t make themselves stop avoiding it. If that’s happening, you can coach around that part (“your notes are good but your recommendations for followup are too scanty, this should be 300 words and have six points of contact”)
    – Automate = Make annoying repetition minimal. Can Grover use a text expander to insert stock phrases, or a yes/no form of some kind? Are there ways to adapt the format of the documentation you require that would still meet requirements but make the actual process of entering information less onerous? I’m sure there are HIPAA issues around this, but like, can a ChatGPT-type tool help?

    There’s a strong argument to be made that this is more work for you than should be asked of you, but I think of it like finding disability accommodations. If your employee can thrive and deliver great work if they have manageable supports, then it’s worth creating the supports.

    1. FattyMPH*

      This is great advice! I just want to add, this is not “like” accommodating a disability. This IS accommodating a disability. ADHD (and anxiety) are legitimate disabilities that deserve to be accommodated as much as visible physical differences!

  123. Zzz*

    Is it possible to give Grover a buddy/’babysitter’, who does his/her own notes or other paperwork sitting next to Grover while Grover does their own?

    Just for notes; he isn’t to answer emails/do research/etc. during this time.

    That can help with procrastination and keeping on task/executive functioning.

    It likely wouldn’t be much of a financial or practical expense, either, so it’s likely worth trying.

    You could do that alongside a template (if he gets stuck otherwise).

  124. MCMonkeyBean*

    I have ADHD and while it may take some trial and error to find what works for Grover specifically, I’ve seen a lot of ideas in this thread that are really good options to help people with ADHD. It sound like Grover *wants* to do better at this so I’m optimistic you can get there together.

    IMO the top three things I would try first are:
    1) Set more frequent and concrete deadlines. If clearing the backlog of notes is currently just a vague “this needs to be done” thing, then try setting specific goals of clearing X notes by Y date. And then for new notes there need to be deadlines like all notes need to be done within one week of seeing the patient or whatever makes sense

    2) Creating some forms or templates to make the process easier to start

    3) Making most of the notes *during* the time with the patient. You are forced to focus on quickly finishing the task at hand when someone is sitting right there waiting for you! It seems like this would also improve the accuracy of the notes if they are made right away in real time and maybe it’s even good to send a summary home with the patients.

  125. Gh8u39e*

    I am an administrator for a medical group and have worked with several providers who have issues with delinquent notes. If notes stay open longer than a couple of weeks, we close the provider’s clinic and we won’t let them see patients again until they get caught up. They are paid on production, so that tends to be pretty motivating.

  126. HearTwoFour*

    You mentioned Grover may have ADHD (self-diagnosed). There are many tools and resources out there that could be implemented in your supervision, and Grover’s work habits. There are ADHD podcasts that could help. (Peter Shankman: Faster Than Normal, for example. He also wrote a book.)
    Grover doesn’t need an official diagnosis to work with these tools. You can even research and implement these habits with Grover without even talking to him about a diagnosis. Do it on the sly and see if it works.

  127. HearTwoFour*

    Sorry – You can even research adn implement these habits with Grover without even talking to them about a diagnosis.
    I apologize for the slip, and wish there was a way to edit my comment.

  128. sunnysouthcoast*

    I was struck by Alison’s suggestion of ‘Have them spend the last hour of every day in your office, working on notes in your presence’.
    I know you presented it as something which would be unpleasant, but – speaking as somebody who has ADHD and struggles with procrastination as OP’s colleague does – if my line manager was willing to offer something like this, I’d love it. Being in a room with somebody massively helps me focus, even if we’re both working on separate tasks.
    So if OP is willing to offer something like this, it might be worth suggesting – maybe the person would jump at it…?

  129. Wedge Tailed*

    I’m a Grover. This letter kicked me in the ribs…

    What worked for me:
    – Therapy. Out of pocket, not EAP – it’s not long enough. Took 6 months to get things under control, and another 2 to realise that staring at the computer screen for hours was me dissociating (writing notes had that many anxiety triggers).

    – Creating additional calendars and listing each task/note as a calendar entry (we used Google calendar). All the entries were kept under Sunday, and moved into the time slot I completed them when I completed them (if I ‘planned ahead’ tasks would pass by without being done). Undone tasks were moved to next Sunday, rinse and repeat. Helped me track what I was spending my time on, and kept everything in one place where I could see it – I tried to-do apps, spreadsheets, post-its on a white board – nothing worked, it all needed to be in one place that I HAD to look at multiple times a day. Let me visualise how big the backlog was. Also let me see that I was spending 1.5hrs writing a support letter so that I could a) learn how to write them much faster, and b) plan for more time to write them until I got faster at it. Only my regular calendar was visible to the rest of the organisation, so nobody else saw what was going on.

    – This YouTuber, and the acceptance of dot points in case notes

    What did not help:
    – The usual time management/procrastination strategies. None of them!
    – Lack of guidelines about ‘good enough’ documentation, after being told that my notes weren’t good enough (my notes were subpoenaed and the feedback from grand boss was that they were great)
    – After flagging the issue with my manager, disclosing my anxiety disorder and keeping him updated (in generalities) about my progress in therapy and all the solutions I was trying/finding, having him shame me for failing, assume that it was an attitude problem, surprising me with new tasks with immediate deadlines, making passive aggressive comments about ‘peoples mental health’ in front of the team, telling my team members he was worried about my mental health, and asking them to make shaming comments and tell me that I’ll get fired if I don’t fix the problem immediately (They didn’t, to their credit. I found out after I’d jumped ship. Did I mention that it was a mental health service…).

    OP, however this turns out, thanks for being a better manager for Grover than mine was for me!

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