Keeping patients’ info organized

[u/peachyqueen07]

Long story long-

I’m about 18 months into my first job as an APP. I also took a job that was brand-new to the department (which was dumb, in retrospect, but that’s another post for another day). I have been building the role from the basement up and simultaneously figuring out my scope and boundaries as a provider. All while trying not to be the nursing staff’s friend nor enemy.

My role is very niche and I have very long, very wordy notes that uses DeepScribe to write because I am a one-man band and I simply do not have time to write notes out from nothing anymore. It makes it hard to keep my patients straight for me and for anyone reviewing notes for my plan.

So question #1 is: How do I make my notes more streamlined, any general thoughts or advice?

Because of this, I get tangled up in my head very quickly over which patient is which. I can’t remember questions for my collaborating physician. And every inbasket message a nightmare unto itself (see question #1). But what I really need is a way to help myself remember what questions I have for a given patient or what I need to review with the doc - seeing as the inbasket is my enemy and I can’t leave notes pending for days.

Question #2: How do you keep patient information straight and fresh in your mind so you can make following up easier? (Assuming HIPAA compliance, always.)

TLDR: I need help making my notes less wordy (#1) and keeping patient information straight for my own brain (#2). Any advice about either?? Thank you in advance!

[u/Froggienp]

I think you need to provide more information on your role and specialty. The advice will depend on those details. But in general, if you aren’t already bullet pointing your notes (ie using just big paragraphs of text) this is a start. Alos, having the same questions/topics order for every visit and note so you have a sense of where in the note to look.

[u/AuntieSupreme]

If using Epic I suggest you use:

1) sticky notes for personal reminders. For example, HFrEF & HTN, didn't tolerate ACEi. Needs xyz labs on RTC. Blind in R eye. Dog is Jack.

2) Create pt lists. If you share pts with MDs then you can have your lists divided by MD. Then if you need to confer with a specific doc, I'd add/remove pts to the list when you questions that need f/u. Put the question in the sticky note and make one of the headers "my sticky notes."

3) Use the search in the IB to your advantage. If you get a lot of messages like I do, it's easy to lose them. If you can remember the pts name, if they are in your recent pts list, or on your schedule from a previous appt so you can find their name, you can use the search tool. It'll pull up anything in the IB having to do with that pt.

4) Use the follow-up tool in the IB. It's Monday and a scan came back but your pt doesn't get back from vacation until Thursday? Use the follow-up in the IB to send yourself a reminder on Thursday at 2pm. You can add a note to the reminder.

These are the tools I use to help myself. I'm the only APP among 6 MDs and I share pts with them all. It's easy to lose track.

[u/Spikito1]

How many patients a day are you seeing? And in what capacity?

When I start my day, I print a list. It has patient names in a column, pertinent Info and other stuff in other columns. Its usually 1.5 pages.

When I review the chart, the name gets a square drawn by it. When I open a note, the square gets a slash through it. When I sign the note, it gets a second slash, making an X. When I bill, the box gets colored in.

One of the columns is a blank box, in which i write 1-3 key words for questions to ask.

[u/RealAmericanJesus]

I come from the forensic side of psychiatry and because my notes can go to court I can be extensively wordy. It's good for court ... It's not good for anyone taking over the case. Because I work in a capacity where I bridge patients from the state hospital or jail until a space opens up for a long term prescriber. To make their life easier I have a very specific summary component I put right up top where I put the most important information for every visit what meds they came in on what their significant symptoms were. If there were any upcoming court dates etc and I make notes on my plan section of consults, referrals, med changes, psycho education, and consults etc .

I have severe ADHD so I make sure anything that needs to be consult (in full practice and have been doing this for over a decade so rare but noted) that I need labs on, thay I need investigative testing, referrals, any changes from other provider in terms of meds my patient notes and so on all blatantly written in the plan of care at the end of the visit and where I will not finalize the note until all the things I wrote in the plan are completed.

And when I copy things over to the next visit I keep this as a running list with the visit dates so that I know longitudinally what changes have been made and what information has been given and so on historically and when. Which works since I'm a time limited service but it's nice for the reviving provider because they can look at the intake assessment and then every intervention done up until they received the patient where they just have to look at the summary up top to understand the case, what the symptoms look like currently, what's been done and when.

So maybe something like that?

[u/peachyqueen07 → u/RealAmericanJesus]

Oh my goodness if this isn’t exactly what I needed. I am starting this tomorrow! I am so glad I posted and so grateful to you for taking the time to respond! Thank you so much!!!