Today in the chart

Note Taking Tips for Busy Clinicians

Documentation is a lot work to get down promptly and accurately. Whether you use handwritten notes or a computer program, here are some tips to help you get the job done.

NPs and PAs have many patient interactions daily, but all of that time can be wasted if you don’t get the notes down from the visit promptly and accurately. So, whether you use handwritten notes or a computer program, here are some tips to help you finish the job.

For Handwritten Notes:

  1. Choose a consistent format: Use the same notebook or notepad daily.
  1. Start every page with the date and time in the same position at the top of the page.
  1. Use a separate page for each patient: You do not want to confuse one patient’s notes with another! Put their name on every page.
  1. Use abbreviations whenever possible: You can even make up your own shorthand.
  1. Have patients complete history forms so you can start with new information.
  1. Follow a regular pattern of questioning so your notes will develop a regular sequence.
  1. Take down patient responses clearly but briefly: Ask them to repeat if necessary.
  1. Note all evaluations, assessments, and recommendations: Always note new prescriptions and changes to current medications, as well as tests and assessments administered.
  1. Write notes during the patient interview and complete them before the end of the same day: Your memory will not be as good once you leave the office!

For Computer-Based Notes:

Many practices require you to use proprietary systems or commercial software programs to enter notes during clinical visits or later from your handwritten notes. Usually, there will be standard sequences to follow in the patient interview, and the software will dictate what needs to be entered. 

Here are some additional guidelines:

  1. Make sure to have an administrative staff member walk you through the software before you try it with a patient.
  1. Ask for documentation on the software: Read it and keep it handy as a reference.
  1. Know who can troubleshoot: There’s always that genius in the office who knows how to get you unstuck and fix glitches and blow-ups that can interfere with your clinical day. Find out who that person is and introduce yourself!
  1. Keep notes objective and clear: Write what you observe and hear without interpretation. You want notes to provide facts that can be evaluated later.

      5. Have a backup note plan: Keep your laptop or notebook handy in case of computer failure. You can always transfer your notes later!

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