Teaching Charting

[Acebecker]

Hired a new grad NP and trying to teach him our computer system by having him scribe for me (this is how I've taught all new grads and how I learned the system).  He is having trouble with...  Charting.  Doesn't know where to put stuff (HPI, ROS, physical exam findings, etc.).  Some of this is being new to our EHR, but a huge chunk is just what I believe is a lack of experience doing his own charts.  Other than getting him more familiar with the EHR, any advice on how to teach providers to document stuff?

[PA-SGuy]

Is he/she using templates? I've found that helps a lot as a student trying to chart. Other things i've done: googled "how to chart xyz" and look at the examples for like MSK exams or getting a physical diagnosis book which might have example notes.

[camoman1234]

OPQRST - HPI is what I used and still use as this was the hardest part for me when I was a student. Now I do my ROS within my HPI.

As for PE, that should be standard stuff taught in school as well as ROS (asking questions). 

I am not sure what the NP is getting confused. Please give use and example or two so I can further understand and maybe to assist you. 

[Acebecker]

Mostly the problem is knowing which systems to document PE findings in (eg enlarged anterior lymph nodes under the lymphatic system vs. the skin system) and understanding how to document an HPI in the HPI component of the note.  Most of the problem has stemmed from the provider documenting HPI stuff under ROS and not really doing an ROS, just multiple HPIs (for the same problem).

So far the guidance has helped.  I'm trying really hard to be open minded about this provider and team player - if I'm not being generous, I'm hoping y'all will let me know.

 

 

[camoman1234]

That sounds like a problem with the NP program not teaching that basic stuff...I think not knowing where to chart (the location of them) lymph nodes is a very basic lesson taught in anatomy...I would would the NP what book they used for this...Bates could be helpful.

[GetMeOuttaThisMess]

Mostly the problem is knowing which systems to document PE findings in (eg enlarged anterior lymph nodes under the lymphatic system vs. the skin system) and understanding how to document an HPI in the HPI component of the note.  Most of the problem has stemmed from the provider documenting HPI stuff under ROS and not really doing an ROS, just multiple HPIs (for the same problem).

So far the guidance has helped.  I'm trying really hard to be open minded about this provider and team player - if I'm not being generous, I'm hoping y'all will let me know.

 

 

I’ve seen the same.

[thinkertdm]

Here is my template, carried with me from job to job.  I just delete what I don't do/see: (some of it is pulled in from epic)

Quote

PATIENT:  @NAME@
MRN:  @MRN@
DOB:  @DOB@
DATE OF SERVICE:  @ED@

PRIMARY CARE PROVIDER:  @PCP@

CHIEF COMPLAINT:  @CHIEFCOMPLAINT@
HISTORY OF PRESENT ILLNESS:
@NAME@ is a @AGE@ @SEX@ who is here today reporting that ***

=======================================================
*HISTORY*
=======================================================

@PMH@
@PSH@
@FAMHX@
@CMED@ 
@ALLERGY@
@SOC@

REVIEW OF SYSTEMS: 
As per HPI

=====================================================
*OBJECTIVE*
===================================================== 

PHYSICAL EXAMINATION:
VITALS:
@VITALS@
@WEIGHT@

General:
    seated on examination table, NAD
    appeared to be stated age.
    was alert, oriented, and cooperative.
    language was fluent and appropriate.
    mentation seemed normal.

HEENT:
Head:
    normocephalic and atraumatic
    felt afebrile
    face symmetric

Eyes:
    anicteric, without injection or discharge

PERRLA.
    EOM's intact without nystagmus in all directions.
    Visual fields were intact by confrontation.
Ears:
    Bilaterally:
        canals clear
        external pinna nontender to palpation
        TM's slightly bulging but nonerythematous
        Hearing grossly intact
    Nose:
        Nares patent bilaterally
        Nasal mucosa was moist and pink
    Mouth and throat:
        Oral mucosa was moist and pink
        No pharyngeal injection or tonsillar hypertrophy
        No masses, lesions, or exudate
        Native dentition was intact in maxilla and mandible
        Tongue and uvula were midline
        Tongue and soft palate rose symmetrically

Neck:
    Smooth and supple.
    No anterior cervical lymphadenopathy
    No supraclavicular lymphadenopathy
    No thyromegally or tracheal deviation
    Carotid pulses were intact, 2+
    No carotid bruits were auscultated
    No discernable jugular venous distention

Lungs:
    Was breathing without difficulty
    Clear to auscultation bilaterally
    No rhonchi, rales, or wheezes 

Heart:
    Regular rate and rhythm
    No murmurs, rubs, or gallops.
    Normal S1, S2. No S3 or S4. 

Abdomen:
    Soft, nondistended.
    Normoactive bowel sounds in all four quadrants
    No hepatosplenomegally
    No tenderness to palpation throughout
    No guarding or rigidity noted.

Back:
    No spinal step offs
    No deviation from midline
    Back was straight and even. 

Pulses:
    Radial pulses were patent and symmetrical, 2+
    Dorsalis pedis patent and symmetrial, 2+

Upper extremities:
    Bilaterally:
        Normal muscle tone and bulk
        Strength in upper extremity was 5/5 throughout
        DTRs at biceps, triceps, and brachioradialis 2+ without clonus throughout
        No significant dysmetria noted with finger-to-nose
        Skin on hands warm and dry; skin turgor intact on dorsum of hands
        Nails show no pitting, ridges, or pallor
        No pronator drift
        No noticeable distal tremor, either at rest or with movement

Lower extremities:
    Bilaterally:
        Normal muscle tone and bulk
        Strength in lower extremities 5/5 throughout
        DTRs at ankles and knees were 2+ without clonus
        No pitting edema noted
Gait:
    smooth and even, without ataxia or antalgia

=====================================================
*Assessment/PLAN*
===================================================== 
@DIAG@

Continuity of care: I discussed that the examination and treatment received was given on an acute basis only, and is not a substitute for complete medical care. I stressed that it is important that a relationship be established with a primary care provider. No ongoing doctor-patient relationship was established by this visit today.

*** TDMSTTREATMENT

Author:  @ME@ @TD@ @NOW@

 

[EMEDPA]

It is fine to use a macro as long as you remove all the stuff you didn't do. always takes a while to get the new scribes to understand that they shouldn't document pelvic and rectal exams on folks with ankle sprains. most of them use nl male or nl female macros for everything and just change the system related to the complaint. that doesn't work, is fraud, etc for most exams as we don't do complete H+Ps on every pt we see.

[thinkertdm]

Yeah, don't forget to delete if you use templates.  personally, I feel documenting the physical exam helps me (and anyone who reads my note) for what I saw.  I can't tell you how many times I have found murmurs that have not been documented, patients without legs who can apparently ambulate, things like facial asymmetry that would have been nice to know existed before.  

Many of the items can be filled in just by looking at them- ambulation when you walk them out, ears when you hug them goodbye, etc.  

 

[SCPA]

1 hour ago, thinkertdm said:

....ears when you hug them goodbye, etc.  

 

When you what!? lol 

[thinkertdm]

 Remember, hugs not drugs.  Especially with sarcoptes.  

[jwells78]

10 hours ago, Acebecker said:

 

Mostly the problem is knowing which systems to document PE findings in (eg enlarged anterior lymph nodes under the lymphatic system vs. the skin system) and understanding how to document an HPI in the HPI component of the note.  Most of the problem has stemmed from the provider documenting HPI stuff under ROS and not really doing an ROS, just multiple HPIs (for the same problem).

 

Agree with previous.

 

All my medics struggle with this; it's tough if you arent familiar with it and I don't think most NPs are taught this in school the way we are.

Need to practice SOAP notes format (all providers should be skilled at this IMO).

Go over ROS and stress pertinent positives and negatives.

Grab a Template off the net and review the PE portion.

 

I also find, with my students, that being forced to rewrite a note 2-3 times incentivizes finding the light.  ??

[narcan]

If this provider doesn't know that lymph nodes are part of the lymphatic system and not the skin, then you have bigger problems than how to teach them the EMR.

Welcome to medical education in the era of for-profit online universities (no offense to anyone who graduated from one of these places and is not an idiot).

[SedRate]

14 hours ago, Acebecker said:

Mostly the problem is knowing which systems to document PE findings in (eg enlarged anterior lymph nodes under the lymphatic system vs. the skin system) and understanding how to document an HPI in the HPI component of the note.  Most of the problem has stemmed from the provider documenting HPI stuff under ROS and not really doing an ROS, just multiple HPIs (for the same problem).

So far the guidance has helped.  I'm trying really hard to be open minded about this provider and team player - if I'm not being generous, I'm hoping y'all will let me know.

 

 

I would try to explain it as plainly possible. Review SOAP note outline and resource such Bates. Dr. Google has plenty of SOAP/ROS/PE/H&P examples. Perhaps print off a template of each for them to refer back to.

Hpi: patient's subjective reporting (aka patient's answers to your open-ended questions based on CC). I use OLDCARTS. 

Ros: pertinent positives and negatives (aka yes or no questions related to relevant systems involved).

Exam: objective findings (aka what you see, touch, hear, or smell during encounter)

 

[Kaepora]

This is my general H&P outline:

Patient identifiers

allergies

meds

CC

HPI using OLDCARTS to address each health problem/diagnosis

PMHx

PSHx

Social

Family

ROS

PE

Assessment

Plan

Obviously consults and progress notes are a bit different.  If this person doesn't know how to chart within those sections... well... that's an issue.  Was he not taught this in school?  Did he never write a note in clinical?

 

[CAAdmission]

On 1/23/2018 at 11:34 AM, Acebecker said:

Hired a new grad NP 

I'd say thats the root of your troubles right there.

[Acebecker]

6 hours ago, CJAdmission said:

I'd say thats the root of your troubles right there.

Trying to be a team player; when they asked me what I thought I advised that we look at experienced PAs that were interested in the job.

[runforhotdogs]

On 1/25/2018 at 0:27 PM, Acebecker said:

Trying to be a team player; when they asked me what I thought I advised that we look at experienced PAs that were interested in the job.

Why would you defend yourself against trolls? If I saw  meta analysis that show there's a diff bet the two then I'd buy it. Until then this is as relevant as saying the left hand is more advanced then the right hand.

[Acebecker]

7 hours ago, runforhotdogs said:

Why would you defend yourself against trolls? If I saw  meta analysis that show there's a diff bet the two then I'd buy it. Until then this is as relevant as saying the left hand is more advanced then the right hand.

To my recollection there is.  Right out of school NPs are behind the curve.  Not on par with PAs until 2 years out of school, IIRC. 

[Miaow]

I teach PA students and we have a class called Clinical Problem Solving Skills which literally is about solving cases and writing SOAP notes and lasts 2 quarters. 

[Kaepora]

3 hours ago, Acebecker said:

To my recollection there is.  Right out of school NPs are behind the curve.  Not on par with PAs until 2 years out of school, IIRC. 

I would actually really like to see this.  Can you post it?

[lemurcatta]

This is kind of amazing because I was taught how to do a focused history and physical, and document it properly the in my paramedic program... including HPI with opqrst/oldcarts and the ROS (we were taught to think of this section as pertinent positives/negatives by organ system or complaint). I actually teach many of these same things to my entry level EMT students.

Now that I think about it, paramedics might actually have more required clinical hours (120 ED hours, 460-720 intern hours on the rig) than NP students. 

There are fantastic NPs, but so many of their education programs are garabage. 

[runforhotdogs]

 

10 hours ago, ACNPstudent said:

I would actually really like to see this.  Can you post it?

A cursory examination reveals the following articles. I did not find too much current relevant studies bet PA and NP. Mostly NP vs physicians.

Even then, there was really no discernible diff in outcomes. So, if I was to guess on the quality diff bet PA and NP. I am not sure its statistically significant.

I am not sure what the big deal writing SOAP notes are since I've had a semester of didactic in it and another 2 entering it in treatment planning at school (different curriculum and field than PA/NP). It's all on an EHR template. I know a NP who just retired. She worked in private practice and taught PA's in Touro. So Touro has DO students who take classes with PA students who get taught by a NP.

Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review

https://journals.lww.com/ccmjournal/Abstract/2008/10000/Nurse_practitioners_and_physician_assistants_in.25.aspx

Primary Care Outcomes in Patients Treated by Nurse Practitioners or PhysiciansA Randomized Trial

https://jamanetwork.com/journals/jama/fullarticle/192259

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

http://www.bmj.com/content/324/7341/819.short

 

Primary Care Outcomes in Patients treated by Nurse Practitioners or Physicians: Two-Year Follow-Up

http://journals.sagepub.com/doi/abs/10.1177/1077558704266821

 

[runforhotdogs]

16 minutes ago, lemurcatta said:

This is kind of amazing because I was taught how to do a focused history and physical, and document it properly the in my paramedic program... including HPI with opqrst/oldcarts and the ROS (we were taught to think of this section as pertinent positives/negatives by organ system or complaint). I actually teach many of these same things to my entry level EMT students.

Now that I think about it, paramedics might actually have more required clinical hours (120 ED hours, 460-720 intern hours on the rig) than NP students. 

There are fantastic NPs, but so many of their education programs are garabage. 

Hehe, you may be right. Many schools have stupid curricula. I wouldn't blame the students having to go thru those programs though. It's funny that I don't see people posting their materials and their best practices on this forum somewhere on a README or in a file repository for future grads to look and compare or to customize to their needs.

[CAAdmission]

9 hours ago, runforhotdogs said:

She worked in private practice and taught PA's in Touro. So Touro has DO students who take classes with PA students who get taught by a NP.

I'd be careful using Touro as an example of much of anything - they got caught selling degrees to students a while back.