Transcript: New Nurse Practitioner Visit Routines

​Liz Rohr:

Hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple. The weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So, if you were wondering about how to organize your visits, what information you should be getting, and what you should be documenting, especially with new patients, physicals, followups, and sick visits, this video is for you.

This question comes from [Myesha 00:00:28], so thanks so much for reaching out about that. A couple of notes. This is a lot of information. I'm going to be going over it pretty quickly to save you some time because I know that you're really busy, but I've made a handout for you below this video that you can literally print out and take into each visit with you, or you could download it now, pause, and follow along with me. And then the other thing to say is that I'm talking about adults. I'm not talking about pediatric visits and I'm not really addressing all of the geriatric components of a physical exam that you could talk about. Then another caveat to add is that this is your kind of like best-case scenario, this is what I strive for, but I do not get this every single time. And don't beat yourself up if you're not able to get all this information, because it's a lot.

But this is the ideal for holistic care, all the information that you'd want to get, and just gradually working towards that. It really depends on the day that you're having, the patient that you're dealing with, the schedule. It's just do the best of you can. So, one other thing to add is that preoperative exams deserve their own video, so if you've been asking me about that, I'm not ignoring you. I just want to make its own video to touch on that as a topic, so I'm not going to be talking about that today.

But, jumping in. So new patient appointments. For new patients, this is the information that I try to get on every single patient, but the ideal visit for this is when you have a dedicated new patient appointment. So, if you don't get to all Of these things, it's okay. You can see them the next time and get more information.

But for new patients, what I do is, and this is maybe a controversial thing, but I open with, "Do you have any questions or concerns today?" And it's crazy that that's a controversial thing, but a lot of people will tell me, "I don't open with that because I just don't have enough time and I'm not going to be able to get the information that I'm looking for and they're going to dump all these problems on me."

That's okay. I still ask anyway, because you know what? People are going to be upset. They're coming to a healthcare provider for a reason, and if you're not asking, they're going to bring it up anyway, or they're going to leave really unhappy. So, it's okay if they throw 17 problems at you. You don't have to address all of them. But opening with that shows that you care, that you want to help them. And you can kind of break it down and set some limits in terms of how many you can address today, and how many you can address at each visit. In the video of how to make a plan of care, I talk about this and I'll link to that video down below. But, I open with, "Do have any questions or concerns today."

Next, I look at medication. So, sometimes when I ask about past medical history, I'll ask if they have any medical problems and they'll be like, "Oh no, no, I'm fine." I do the same thing. Whenever I go to seek care, I'm at a specialist office and they're like, "Do have any family history?" I'm like, "No, everything's fine." Like, that's not true. It's just like without having cues. So, that's one of the things I want to say about medications. So when you ask them medications, you get a lot of information, like are the on lisinopril, metoprolol, aspirin, things like that, and so additionally, is it will give you that information about medical conditions, but then once you'd go to the next step, which is past medical history, you can kind of give it further cues about any high blood pressure, diabetes, thyroid problems, asthma, et cetera, et cetera.

So, the next thing is past surgical history. So have you had any appendix surgery, gallbladder, C-section, tubal ligation, things that people don't necessarily think to volunteer to you. Next one is family history, and I touch on the big five to seven, which are cancer, diabetes, heart attack, stroke, hypertension, alcoholism, and mental illness, because people don't necessarily think to volunteer any of those things and that's really relevant for their own personal healthcare and screening. Hopefully also it'll jog their memory to mention if they have a strong family history of like rheumatoid arthritis or something like that or some genetic condition.

The next one is more social history. So, if you're working with a medical assistant, hopefully they've already asked about smoking status, alcohol, and illicit or recreational drug use, and allergies, of course, but I endeavor to ask this because it gives you a lot of information also about their health risks in general. So, who do they live with? What kind of work they do, if they're working. If they have any sexual partners or what are the genders of their sexual partners, it's a kind of sensitive way of asking that question. That is a topic in and of itself, getting a sexual health history, and so I'm not really going to jump into that into in this video, but I tend to get into that a little bit more at the physical exam, especially because people aren't necessarily willing to share that when they first meet you. But, occupational exposures are really important in terms of like, what kind of work they're doing. And then the sexual history kind of gets into contraceptives. Do they take any contraceptives? Are they interested in that if that's relevant to them? Depending on their partners and their behavior.

So, yeah. After that, I jump into looking at vital signs. Doing a basic exam, heart and lungs. It really just depends on their complaints. And then ideally at that point, you're kind of concluding your business and you're going to request the records from the previous PCP, if you can. If they're out of the country, typically I'm not able to get that information, but sometimes a family member who lives there still can take a photo of their vaccine record and send it to you, stuff like that. And then depending on how your clinic works, you can have them come back for a physical in a month, 2 months. It really just depends on how you do that.

A note about billing. This is another topic in and of itself. But, when you have a first initial visit, if you do an ICD-10 code of establishing care, that's a Z code. So, Z codes are reimbursed a little bit differently than a like true code. So, for me and the insurances that we typically take at my clinic, I'm going to be asking, obviously, if they have any concerns, but if they have no concerns at all, like no toe pain, no controlled asthma that we have a brief discussion about, nothing like that, I'll probably turn it into a physical because our physicals are 15 minutes at my clinic anyway so I might as well just add on the physical part, and then I can bill for a physical code, which is reimbursed differently than a Z code. Anyway. But just something to think about.

The next type of visit is a yearly physical, and so I take all the information from the new patient visit, if I haven't gotten it already, I'm going to be getting that information. I'm going to be updating it, any updates to their surgical history, family history, stuff like that, and I'll kind of review what I have there. I'll talk about a new medications, things like that.

Then I'm kind of adding on a full review of systems and a full physical exam. And so, again, this cheat sheet, if you haven't downloaded it already, if you haven't paused and downloaded, you can literally print this out and bring this into every single visit with you, and I did this for probably a year, if not more of having a piece of paper with a checklist or use my EHR to ask them to review of systems. And that is not a marker of your intelligence and your capabilities as a nurse practitioner. That doesn't mean anything if you've memorized an ROS. It's all about giving safe care, so there was no shame in doing that. I have a student with me right now and she feels like it makes her feel very safe, and it does, because you go through and you check it off and you've done your job and you're doing a good job.

Yeah, so I'll do the full ROS, the full physical exam, I'll look at preventative. So, I follow USPSTF, and then depending on the conditions, looking at various guidelines, that's la big topic, but that's kind of a good starter one to go for. Like colonoscopy, mammograms, other types of screening, any blood tests that they need to do. Things like that. I also talk about plate method of dietary, kind of getting some dietary history, physical exam, talking a little bit more about the self physical activity, rather. So like 30 minutes, most days of the week, if they're getting 10 minutes, three times a day, it's the same as about 30 minutes every day. Something light, just walking, try and get that done. If you can. All the benefits of doing that, et cetera, et cetera. Getting a little bit more into sexual health history if they feel comfortable doing that. Talking about the dentist, vision, stuff like that. So, just doing your best.

Again, this is a lot of information and if you only have 15 minutes for your physical, if you don't get it all done, just again, try your best, have them come back sooner and all that.

The next kind of visit is a follow-up visit, and so this really depends on the type of reason that you have for follow-up. So, is it diabetes, is it high blood pressure, is it thyroid. So, I tend to focus on their symptoms, so what are symptoms that it would be getting worse or it's uncontrolled or controlled? So diabetes, like polyuria, polydipsia, vision changes, numbness and tingling, stuff like that. And then medications that they take and I ask about adherence. And I try to ask in a very nonjudgmental way of, "How many days per week do you take your medications? Are you taking it some of the time, most of the time, when you remember, every day." Because the people who are taking it every day are going to volunteer that information to you very, probably, so you're not going to offend anybody by doing that.

And then I'm going to be looking at the parameters of assessment. So is it a lab test? Is it the blood pressure? Is it their blood sugars? Things like that and kind of making adjustments from there. And then I'm doing relevant physical exam, so heart and lungs is pretty standard for most patients, but if you're doing a thyroid exam, if you're doing the foot exam, if it's diabetic, things like that. And then deciding when to come back, is it 1 month because it's really uncontrolled, 3 months, 6 months or a year, and I can make an entire video just about that kind of decision-making.

Yeah. And then the next part, and I try and do this for every patient, is just looking at their preventative. For most visits, I really endeavor to do this where I'm looking that it's really nice in our checkout form that it correlates with the EHR of when their last physical was, mammogram, colonoscopy, et cetera, et cetera, and I can kind of just look and see like, "Oh, this patient's due for physical this time. They're due for mammogram this time." And so I can kind of schedule when is the next time they're going to come back depending on their chronic conditions and also their preventative stuff.

So, sick visits. That's the last one I'm be talking about today. For sick visits, it's not always going to be the patient that you've done your due diligence of work of getting all that baseline history. It's somebody that you might not know. I mean, if you're brand new, you probably don't know anybody, but once you get your panel going, if you have a panel, that's how you operate, you might be seeing patients from other people's panels. So I'm kind of doing like a very quick refresher because that can take a lot of time to get all that information.

So, if they're coming in for a cough, I'm looking at their medications that they take, their medical conditions, and relevant family history, surgical, really briefly in terms of the histories page, before I going to see them. And then I also use my old card method, so it's onset, location, duration, associated factors, relieving factors, and time. There's other ones like PQRST. It's in that handout if you want to check that out, but it kind of guides my questioning in terms of history gathering and all that for the problem-based visits. So like, when did it start? Are you feeling better, worse, or the same? Are you taking any medications to help it? Do you have chest pain, fever, chills associated with your cough?

You can refer back to the how come up with a plan video, but the main points for this type of visit is, what are the alarm signs? When should they be feeling better? When should they go to the ER? What symptoms would they have to present to the ER? And then when do they follow up with their PCP? So, looking at their last notes, are they due for a diabetes follow up, are they due for hypertension follow-up, are they due for their physical? Kind of looking as you're wrapping up to, "When should they come back?" Because you should always be thinking about, "When should they come back as needed, annual physical, or chronic conditions?" Because it's good healthcare for them. It's also good business for the clinic, so you can stay open and give good care to people, but it's just about good care.

So, that's it. Did you like this video? If so, hit like and subscribe and share with your NP friends so we can together we can read as many new grads as possible to help make their first year's, year plus a little bit easier. And don't forget to sign up for the email list over at RealWorldNP.com. You'll get the Ultimate Resource Guide for the New NP. The videos will go straight to your inbox with little notes from me and bonus that I just don't share anywhere else. Also be sure to find me an Instagram or Facebook if you use either of those. I post even more tips and tricks of the trade, and I'd love to connect with you there.

So stay tuned for the next couple of videos. I'm going to be doing the preoperative exam. I'm going to be doing two other lab interpretation videos. And another really exciting thing to think about is that I've got a lab interpretation, a crash course for new nurse practitioners that I'm working on. Oh, I'm so excited for you to have this because I think it's going to just make you feel so much better. It's the lab course that I wanted when I was a new grad and it's turning out even better than I had hoped. So, it's going to be in the next couple of weeks, so if you want to hear about that, go to RealWorldNP.com/labs, and you can sign up there and I'll keep you posted when I have some updates. Thank you so much again for watching. Hang in there and I'll see you next time.