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Seeing patients, writing things down, and thinking all at the same time

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I'm a PA-S and find it very difficult to see patients and take notes at the same time. Even if I am constantly writing I feel a) I am not giving them adequate attention and b) I am not able to think that well and write at the same time and c) even as hard as I try, I have to leave a lot off and later don't remember exactly what I asked them. I would like to just write down positive findings and drugs but we have to chart denials too.


We are told to write things down but never have been given any real advice besides don't chart eg "denies familial cancer" if we didn't ask. So I find myself feeling frustrated that I'm either not doing my job right in seeing the patient, or that I'm not charting accurately.


Seasoned PAs shed some advice please? Should I just write down the bare minimum and focus on my patient or do you just write it down as soon as you leave the pt room or what?!

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I'm not sure it gets better. I've been at this for over 30 years and I hate the fact that I can't make good eye contact with the patient the WHOLE time they are talking to me.


I type my own notes in real time. I have created many "toggles" and short cuts that allow me to write whole sentences or paragraphs with one key stroke. That helps. I do record all vital information.

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I had a similar problem as a PA-S. As time goes on, I think you train your brain to work differently. For instance, I no longer have to think as hard about which questions to ask, and I tend to retain the answers much better. I try to do as much of my note as possible in the room, but sometimes that doesn't happen. (Sensitive subject where I just feel eye contact is more important, or maybe my computer locked up AGAIN....) Yet, I can walk out and remember everything we talked about. I know it's not much comfort now, but it really does come with time and practice.

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I think patients expect you to write things down and make notes, and not stare at them. When they are relaying something obviously important, put your pen down, listen, nod, add a few mm-hmms, wait for them to finish, then pick up the pen, and say "Oh my, let me make sure I have this straight...your headache started after you fell on your head?" watching the patient for both verbal and non verbal cues. Then quickly write down "ha p fall".

Obviously, this happens in a matter of seconds, and can be truncated when they are relaying cold symptoms, but it is important to watch the patient but also record your observations. Its one of the skills you are learning. You'll also find you remember more than you think.

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Just a fellow student, but here is what I have found working for me in Family Practice:


Sometimes I front load the visit with "if it's ok with you, I'd like to take a few notes so I can better keep track of what we have covered during your visit". They feel you are listening/paying attention and are invested in what they have to say, despite the fact that you are not lip reading while listening. (staring intently at their face the whole time)


I find the most intensive note taking is during initial visits/evaluations where there are so many different things to cover. But on the focussed or follow up visit of an established patient, the extra note taking is far less and much easier.

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In my practice, I sit across from and offset from my patient during interviews. To the patient's right is the computer, and I keep the monitor at a 45 degree angle, and invite the patient to read my notes as I take them. Mind you, I'm a ridiculously fast typist, so I can *do* that. So, I can gaze back and forth from the patient who is off to MY right to the monitor directly in front of me, making eye contact periodically while typing.

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i have a general template that i use as a habit, so that i get much of the peripheral data out of the way as i find out more about the why they are here.


to start:

why are you here? (generate a quick c/c) then say, we'll explore this in detail, but first tell me a little bit about you: (and then ask-->





PMH: htn, dm, etc .. what ever they list




FmHx (if pertainent)


******************** benefit, most of the time you are asking these questions, you can be looking at him and starting a peripheral exam.. making simple notes on the card...



this data can usually be written down on a long edge of a 3x5 card, maybe needing two columns if detailed pmh, psh or needs more tyhan usual data (eg Cath results)


then, now that you know a whole bunch about them, and their comorbid features, ask them to tell you the salient features of the ==>


HPI: what, when, where, PQRST,things tried, etc


and ROS


typical card would look like this:


47 y/o wm c/o cp

c+1ppd x20y. etoh 6ber/day, 5 d/wk. construction

pmh: htn, t2dm, hyperlipid, pvd , cas

psh : gb, CAE for cas, rt , last u/s "good"

meds: lisinopril/hctz, metformen, BASA, trentyl (have nursing write down dosages, or write it yourself if have time)

allg: pen(rash)

fm hx: pgf&f htn, cad (f cabg at 45), m w/ dm, sibs a&w

PCP: Smith/premier clinic


hpi (now, tell me more) typical hx, risk factors, etc

ROS: by pertainent system, including travel if pertainent


Then i do a PE (note, as I have this process memorized, I can generate the list in my head and usually can remember what is said while I am doing the PE.. this takes practice.. you may want to sit and jot the answers so you do not forget them while you are learning the system), and jot down abnomral findings (bruit rt carotid, fixed pupil right, pleural friction rub)


this practice allows me to gather a lot of info quickly, and, for me, keeps it in a uniform format that I know very well, so that I do not miss much.


I know it does not follow the usual CC, HPI, ROS, etc format.. but I habe found that, by getting the PMH/PSH/Meds, allergoes, etc out of the way first, I already know most of what is and has been wrong with them long before we every get to the HPI...


It works for me.


when I walk out of the room, I have


1. a complete card withthe h&p in a short hand that easily be transferred to a note

2. discussed with the patient what i think he has and what we are going to do now (labs, ekg, cxr, meds, etc)

3. started to think about a ddx, and jotted these down on the card for dictation/ consideration.


Then, when I dictate the note, it starts with a quick synopsis of the pt as a whole: this 47 y/o wm smoker, moderately heavy drinker, w/ htn. hyperlipidemia, CAS, PVD (etc), presents to the ED for CP, described as sharp stabbing, pleuritic, and worse with laying down, better with leaning forward, rated as a 7/10 when worse, and a 4/10 when leaning way forward. The pain is radiant to his back and both sides of his neck.. it is constant, waxing and waning but not colicky. Has Had SOB, but no dyspnea. felt warm, but no docuumented fevers. some chills, but no sweats, no cough. has had palpitations. denies jaw or shoulder pain. no claudicatioin sx. has had recent URI/influenza. no recent prolonged travel/ immobolization. no reflux sx, no weight loss. h/o pos PPD w/o treatment



ROS: pos headaches, pos blurry vision, mild photophobia on right.no diplopia, dysarthria, ataxia. no jaundice, weight change, arthritis, diarrhea, constipation, heat intolerance, abd pain, dyspepsia, reflux. no weakness, numbness, paraesthesias. etc



Then trqansfer the rest of the information from your card here (allergies, meds, PCP etc)


and your PE findings, and your intial thoughts( medical deciaion making.. which will change as you go along)


The beauty, for me, is that i can shorten it for a simple one system complaint, say a broken bone:

why are you here?

uh huh, that ankle looks bad.. tel me: do you smoke, drink? have any medical problems like high blood, sugar blood, bad blood (or regular terms if pt educated), any surgeries? taking and meds? have any allergies? do you work? gotta doc?

now, how did you do this? (blah blah blah) did you lose consciousness, have any other problems due to this or which contributed to this?)


2 minutes later, full h/pe and plan.


or can expand it, as above , for a more extensive workup.


anyhow, it works for me. you are welcome to it

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it will get easier the more you practice doing a history. eventually you wont have to think so much about what to ask and the process will get easier. I have basic questions for CP, abd pain, cold symptoms, head injury, car accident, etc that I rattle off. You will figure out abbreviations to make the note process easier. for example, if someone has abominal pain, diarrhea 4 times , vomiting 6 times for 3 days i just write- +a pain, +Dx4, +Vx3 x 3d. cough is "c", sore throat is "s.t.", fever is f, etc. You will also eventually remember the history without having to take as many notes. When i first started my job I could barely remember anything about the history without jotting down notes. Now, if i dictate the visit within a reasonable time I can recall most of the symptoms (i still take basic notes though). As i examine the patient i try to think of any questions or ROS that i missed and ask during the physical exam. Thankfully i already have PMH, Social history, meds, allergies, etc on EMR before i see the patient. I usually re-ask meds and PMH regardless, they may have left something off when the nurse checked them in.

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Thanks everyone for the advice and also for the template! So there is hope. I definitely need to learn/create more short hand to save time.


Question for charting with computer vs paper notes. I am currently charting on paper (if in the room). While I do understand the need and how much faster it is to chart on a computer, I have always been personally put off by this when I see a provider and they chart on a computer while seeing me. And this is coming from someone who understands how tedious and time consuming e-charting is, so I can only imagine how someone without this perspective may feel.


For those who have done both, do you have a preference or does your job more or less expect you to chart on the computer while evaluating your pts?

Do you feel charting on a computer, while it obviously saves time, decreases performance with the patient? In other words, do you think using the computer hinders your evaluation and tx of the pt and is a necessary evil, or do you feel it doesn't really make that big of an impact on your work up either way?

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Again, just a fellow student, consider the source.


The clinic that I have been at has 18 providers and uses Next Gen for it's EMR. That program does an Ok job at making access to the patient's previous visits and provider's notes fairly accessible in a timely manner. I can easily review their meds, social hx, all of that in less than a minute or so. I also get the notes from the MA that they entered when they roomed the patient.


As a result, when I go into the room, I put the computer to the side, face the patient, and then refer to the computer when I say "I see you were seen by Dr. XYX on Jan 1 for belly pain, then by Dr. yyy on Jan 5 for chest pain..you were given these meds, at these quantities, on these dates. I see your last EGD showed some flair ups from your heartburn..are you still taking that Prilosec that was prescribed back in October?"


It is my hope/belief, that the patient sees the computer as an asset to provide a more comprehensive health care plan. The patient doesn't have to remember dates, times, doses, or even which meds they take. They don't have to re tell their story a dozen times and I can pull up their labs with a click of a button to check their lipids, CMP, and TSH results right there. It also enables me to print off patient education material at the moment I see them and give it to them before they leave instead of digging through a drawer looking for the old printed ones which never seem to be in stock.


I find it helpful to have the computer with me. It may be a crutch, but it's a crutch that helps me move faster, in a more efficient way, giving the patient an overall better experience. (and care)

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computers suck for charting, they are awesome for looking sh*t up and overall information storage. as for having to write info down while in the room, it comes with time. see a patient and retain all the encounter and the document immediately after

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Can you make a quick template on 5x7 cards? It may help to take this into the room. Questions for common problems can be templated. In time, the questions will become logical for each chief complaint as you will know how the pertinent positives and negatives will influence your recommended testing and / or treatment. When you work with electronic medical records, beware the pre-typed template for physical exam findings - you must examine every minute thing listed.....never want to misrepresent the patient's current condition (ie. if there's an ocular prosthesis, it needs to be identified your note and not have been recorded PEERL! or EYES: normal). As Jen listed, I always review the PHM, PSH, FH and SH even when there were previous entries on the electronic medical record. It's amazing how many of these histories have been "reviewed" but not updated.

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Our computers are currently setup at 60 degree angles BEHIND the patients. Talk about great interaction. I even enter the room now and make a comment to the patient about welcome to the world of modern healthcare as I'm standing behind you, talking, and staring at a computer screen. Surprisingly, no one has complained and many (we've only had our EMR since Nov.) say they understand. Just for good measure, if I know the individual, I'll point out that this is their federal tax dollars at work; 1) more efficient care...strike one, 2) fewer errors due to fail-safe mechanisms built in to EMR software...strike two, and 3) greater communication between providers...strike THREE! I liken it to going to Europe and expecting all the French to be able to speak English.


To get back on topic; I think it just gets easier to remember important details over time. Maybe it's because something atypical about a typical encounter occurs, or you don't remember anything specific because there wasn't anything atypical. The only thing that I was noting when using the paper chart was just the onset of symptoms, location (can't remember left from right), and anything else that might be relevant but forgotten over the next five minutes.

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I had a "come to Jesus" moment in dictating about 15 years ago, when I walked in on my secretary and she was saying, in an angry voice, "What the hell is he trying to say?"


Later I sat down and created a very detailed and organized note for new patients, and follow ups. I've stuck with it every since and have created a template around it with just toggles and drop down choices to fill in the blanks.


My new patient headache note is below and I never wander from it. It is quite simple, yet comprehensive and can be completed with a dozen key strokes:






Natural Course:


Character: Location: Quality: Tmax: Timing:


Associated Symptoms: Photo-phobia? Phono-phobia? Nausea? V omitting? (if yes, how often and when in the headache does it start?), Autonomic? Neurologic (including aura)?


Severity Range: 1-10


Frequency: In the past 30 days how many days have you had a day with a level 6-10? How many additional days 1-5? If more than one attack per day what is the average number per day?


MIDAS: (not always done)


Duration of Attacks:


Modifying Factors: Triggers? Aggravators? Relievers?


Present Treatment: Abortive? (response?) (Number per month?), Rescue? (response?) (Number per month?), Anti-nausea? (response?) Prevention? (duration? response?)


Past Headache Treatments and Outcomes: Abortives? Rescues? Preventative Medications? CAM?


Past Work UP: MRI/CT/Specialty Evals?/Labs?


ROS: (comprehensive and one click fills in two paragraphs with normals or you can type in any positives)


PMHx: (like ROS)


Family Hx:


Social Hx:


Exam: one click fills in a comprehensive exam or modify each item that is not normal.


Impression: ​One click chooses from about five of my most common assessments and then I fill in the rest if needed.


Plan: drop down menu of about 40 choices and narrative if needed.



The Follow up is simple as well:


Previous Plan: (automatically brought forward from the past visit)


Interval History: (has to be a narrative)


Headache Status:


Number of days with 6-10 in the past 30:

Number of additional days 1-5 in the past 30:

Percentage Improvement:


MIDAS Score:


Interval ROS:


Medications reviewed updated the medication list and allergies:


Drop down statement: "I did a comprehensive review of their entire headache history."

I think you get my point but the use of drop down menu, multiple choice and sentences with one key stroke helps a lot.

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