Transcript: Time Management Tips for New Nurse Practitioners

​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. I've been asked a lot about this topic, and that's the topic of time management and how to manage your time better as a new nurse practitioner. And I have a lot of insight to share, so hopefully it's really helpful for you.

In this video, I'm going to break it down in terms of the different ways to save time before the visit, during the visit, and after the visit. And hopefully, the different kind of hacks I have to share can be really helpful. Also, if there are things that I haven't shared in this video that you do that are really helpful for you, I'd love to hear from you as the other nurse practitioners who watch these videos would as well.
 

So jumping in, Before the Visit. The main thing that I did when I was a new nurse practitioner is looking patients up the night before if you're lucky enough to be in primary care and not seeing urgent care patients. To kind of look and see what the patients are coming in for. You can do a brief review of their charts. So looking at their, I kind of do it in this very systematic way. I will look at their problem list. We have a problem list in my EHR. My last job just had their active diagnoses, whatever, however, it looks for you. But whatever their diagnoses list says or their problem list says, their past medical history, past surgical history, family history, just taking a quick peek at those.
 

And not going super into depth because you probably have 20 patients on your schedule and that's a lot of work to do the night before, but just briefly looking at what are their problems, when were they last here, when were their last labs, taking a quick peak of preventatives. Again, this may not be at the top of your priority list when you're brand new, but in terms of holistic care of doing the best you can, looking at their vaccines and their pap and their colonoscopy and all that stuff if you can. If not, just focus on why they're there.
The next thing is to think about what are the different measurement parameters that you have for the reason that they're coming in. Most of the time, it'll be a follow-up for diabetes or hypertension, or something like that, and looking at what are the parameters you're looking for. Are you looking at their A1C? Are you looking at their renal function? Are you looking at their blood pressure? Just looking at those markers, and thinking ahead of making a cheat sheet for yourself of, "Oh, this patient's coming in for this so check this lab," things like that.
 

One quick note about appointment notes. A lot of times, if you can look the night before at your chart, this is variable throughout any different clinic that I talk to people about. If you look at their reason for a visit, it's very variable, number one, if there's going to be something written. Number two, what it's going to say. So it's probably going to be, it may be blank. It may say follow up. Follow up for what? I don't know. And then it may say things like blue urine, which is a true story from when I was a brand new grad. That's a long story, but it wasn't a physiologic... There's nothing that can cause blue urine as far as I understand but she, it was a mental health-related issue.
 

But anyway, when you look at the reason for visit, it may or may not be accurate, and that comes down to a number of things. Patients don't want to say on the phone. And you're also asking nonclinical staff to ask clinical questions, so that can be a little bit challenging. People really endeavor to ask those questions, but sometimes, things come up, right? And then the other alternative scenario is that someone comes in and they have decided that the problem they came in for is resolved and they have something else to share with you, which happens every single day, which was really stressful for me as a new grad but you just, that's just how it works.
 

And you can hopefully work with your staff working with your office to see if you can consistently have a reason for visit written down so that you can prepare the night before like, "Okay, so someone's coming in with shoulder pain. What are the things I'm going to ask them? If there's diabetes, what am I going to ask?" Things like that. But yeah, that's a really hard part about appointment visit notes, that they're usually not that consistent.
 

A couple of other notes before the visit. If you work with a medical assistant team or you work with your own medical assistant, that is the dream and I loved that in my last job. Rose was amazing. Love you, Rose, if you're watching this. She is so good. I would work with her and we would come up with a system. She knew me. She got to know me and what my preferences were, but we also just had a general system. And so hopefully, your medical assistant can ask to save you some time in the visit. You know, they're smoking, alcohol, drug-use status, reconcile their medications if they feel they have the knowledge and skills to do that, or just go through a list with patients and check off or cross off or leave a question mark if the patient's not sure.
 

And then another thing they can do is once they get to know you, if there's standards that you have in your clinic, you can have them do a urine dip if you have somebody with abdominal pain or an HCG, a urine pregnancy test for somebody who's coming in for contraceptive, just right off the bat without even asking questions. Other thing to think about is PHQ-2 screening. What are the things you can come up with in terms of the standards of practice of your clinic to have them help you with that? Because it's so... Keeping in mind that takes a lot of time to do, but in that way, you can be doing other things that are more NP related while they're doing that stuff to help you.
 

Another thing to think about is not really pertinent in my clinic because most of my patients have illiteracy and low health literacy, but it really depends on the clinic and the type of patients you're working with. But if you can have forms that patients can fill out their past medical history, family history, medications. If that they can fill that out while they're in the waiting room, that can definitely save you a lot of time too. That's it for the Before a Visit.
 

So in the visit, a couple of things that can save you some time. I would get sucked into... My visits were 20 minutes when I was a new grad, and I would get sucked into a conversation for the full 20 minutes. Don't do that. One of the things that was just an aha but it makes complete sense is that one of my colleagues had recommended five minutes for your history, five minutes for a physical exam, five minutes for your plan of care, and then five minutes for your note. In reality, I did not take five minutes to write my note. I never got my notes done during the day when I was a new grad, but I could at least break it down, such that I was keeping very mindful of how long five minutes was, because that's not very long at all. And that really helped cut down on the chattiness and the winding conversations that you're having and keeps you a little bit more pointed and directed when you've had that self-imposed urgency.
 

And it may feel rushed at first when you first started doing it, but the reason it's so wonderful to do is because at least when I was a new grad, I would ask the history questions, do the physical exam, come up with a plan of care, which I made a whole video about that, but I would excuse myself from the room because I never knew what to do. I'd go look it up and I come back in, taking at least five minutes to do that. And when I came back in, I'd realized that I had other history questions I didn't ask about that I should've asked, regarding shoulder pain or eye pain or something like that. And it also gave me the time to have that discussion with the patient, and they would reveal their doorknob questions, all the questions that they were kind of saving for the end, even though I had to ask them three different times. If I could help them with anything today, any questions or concerns. The doorknob questions typically happen when your hand is on the doorknob. So that saved some time.
 

Another thoughts are about the ROS. If you're doing, especially physicals, physicals can be really overwhelming. I do 10 physicals a day at my new job, which I didn't really realize going into it but it's fine. I'm used to it now, but it's kind of a lot, to do a physical rather. People think that their physical is to unload all of their issues that have ever happened to them in the last year or in the 10 years since they've seen a doctor. That is not the time and place, however, that's what people expect. So, what you can do, and I talked about this in How to Make a Plan of Care, is kind of setting some limits with them, but also, just making the decision of like, "You know what? If you have multiple problems to address today, we can just do a problem-based visit. And then the next time, we can do the full physical exam because...?"
 

And people don't necessarily like to hear that, however, it's reasonable and it's not fair both for you and for them to address that, which I talked about in that video so I won't get into it too much, but you can make that decision. If it's a physical today and you address too many problems, just have them come back for another physical. Another thing to think about in terms of the physical is that the ROS, their review of systems, I definitely do a full ROS in terms of all of the body systems. And if you saw my video from before where I gave that patient visit cheat sheet, I wrote out all complete ROSs by system. And I'm going to give a disclaimer and I really should have done this when I sent out that video, but my huge disclaimer is I do not ask all of those questions. I ask all of the systems, but I do not ask all of the questions because there is not enough time to ask all those questions, and also it brings up a lot of stuff.
 

And so this is kind of a consensus with experienced clinicians, is that if patients have something that is really bothering them, they're going to bring it up. For example, you're doing a cardiovascular review of systems, you have chest pain, palpitations, syncope, edema, those are pretty important to ask, and so I ask those, but if somebody is having nosebleeds, especially if they're frequent or even if they're infrequent, they're going to be like, "You know, I'm having some nosebleeds." But if you go, "Oh, do you have any epistaxis," it's just... You have to come up with your own philosophy, but typically, that's not just me. That's kind of a shared mentality of let's ask about the most dangerous, most common items in the ROS, and then if people have something further, they can volunteer that.
 

Another thought about really long visits are if you have a new patient with multiple chronic comorbidity. They have heart failure, CAD, they have diabetes, they have IBS, they have gout, and the list just goes on and on. They have 10 to 17 chronic problems. The way that I work around that is that those things all need to be documented. There's a past medical history section, which depending on how your system works, you need to have a problem list or a past medical history section, whatever. I would put that in and I do put it in the problem list section. Anyway, I put it into my EHR and I make notes about like diabetes, diagnosed in 2010, taking insulin, variably controlled, has not seen endocrine, blah, blah, blah. That's in my PMH section. I've asked all of those questions and it's documented, but I don't necessarily have to address it unless I'm doing something about it at that visit. Does that make sense?
 

For diabetes, I'd probably include that because I'm asking about those alarm signs and symptoms because it's, again, it's a triage thing. If you have somebody who comes in with diabetes like, "What are your blood sugars?" Anything above 300, less than 70. "Do you know the signs and symptoms of hyper and hypoglycemia?" et cetera, et cetera. You're taking the most important, scary things and making sure that you're addressing those at that moment. So if it's totally controlled, you've asked all those history questions, you can still put that one in the HPI, but IBS, for example, unless you're talking about dietary modification, going into big explanations, you're adding peppermint oil for them, something like that, that goes in the PMH.
 

You can talk about it, but just brief updates about what's going on with each of these things and what's out of control right now. And it's hard because if you only have 15 minutes or even if you have 30 minutes and they're really complicated patient, it's hard to ask all those questions, but just doing your best and only addressing in the HPI and the plan of care, what you're going to do for each of them. And that's a philosophy thing. Other people have different philosophies. I see notes sometimes that they address seven plus problems, but I really try to keep it four or less in terms of my assessment and plan, because those need to be broken up. That's just my personal opinion. And honestly, in terms of billing, it doesn't matter if you do more than four problems at a time. It's going to be a four anyway.
 

I mean, that's an aside, but that's something to think about in terms of the chronic care. I always go to the alarm signs and symptoms for all of those problems. If there's multiples, we're making sure that everything is safe right now. "What is the one or two things I'm going to do for you today? And when am I going to have you come back?" So if that person has multiple chronic comorbidities, their blood pressure's out of control, their A1C is out of control, they are having a gall flare, that's really hard. You do have to address all of those problems. However, the other things, if it's just the diabetes that's out of control, maybe the blood pressure, address those today. Come back in a week, come back in a month for a full physical, whatever your plan of care is, and then just kind of take it from there.

I'm not very good at time management. I have to work very hard at it. So one of the systems that I came up with my medical assistant at my last job is that she would close up the visits for me. I'd go in, do the history exam, plan of care, go out, step out of the room, order any medications or lab tests or anything like that, and either review the plan of care with them, or if I hadn't reviewed it already, I'd go back in and tell them. But if I had done that all at one time in the visit as I got more experience and I didn't have to excuse myself to come up with that plan of care, she would come back in and do a checkout form. We'd have a checkout form, I'd go to the front desk and say, "You know, what? Follow up in a month," "Follow up in three months physical."
 

And I hopefully have said that already to my patient, but it's just kind of reinforcement because sometimes patients need things said multiple times, and they're going to have questions for you like, "Where's the pharmacy? Where is the... Where do I check out? Where is the lab? When should I come back?" There's going to be a lot of questions that are not necessarily NP-specific, that if you can team up with your medical assistant and they can come in and help you with that, then hopefully that can be really helpful in terms of saving you some time.
 

Another note about after the visit is the notes, of course. The notes, the notes. I don't love writing patient notes, but I am obsessed with templates and quick texts. That is my number one tip for notes. If you don't have quick texts or templates, or something that's pre-saved where you can input something in terms of the HPI, like a blurb of all the questions you would ask for diabetes, hypertension, physical stuff like that or a blurb you can put in for your plans of care for each of those patients, I highly, highly, highly recommend making those. And as a nice bonus to this episode, I actually have a cheat sheet. You can download that. It has my sampling of a quick text that I use and the assessment and plan frameworks that I use for the main problems. You're welcome to use those and adapt them as you'd like.
 

And then the other thing is just getting it done. Honestly, I would agonize, I would take forever to write my notes. I wish I had written it down. I remember I was precepting a new grad at my former job. And we were talking about like, "Oh, how long do you take to write your notes?" I was like, "I try two to five minutes or less," and they were like... And I'm like, "Really, that's all I'm going to take now, because if I've seen 20 patients a day, I don't have that time. I have to spend that time doing all this other stuff." But when I was brand new, I probably spent at least 20 minutes on the note. I did 20-minute visit, 20-minute note, and that's just not sustainable. And most of the time, I was agonizing.
 

And if you're not agonizing, it's probably because you don't know what to do with them. In which case, really you need to reach out. And I'm such a broken record when it comes to mentoring, but definitely set that up if you don't have that already. And I really, really hope that your supervisors are open to that and they're willing to talk with you and meet with you and set aside some of that golden time so that you can save so much of your time, agonizing over charts, looking a million things up that are just not necessarily there, that are clinical judgment things that you might not find in the notes, that kind of stuff in your resources.
 

But anyway, my top three survival tips for the new first year, I talked a little bit about that, how you set that up, mentoring for yourself. One more bonus tip for notes is that people, whether or not you have something fancy like a Dragon software, I think that's what it's called, where you voice record your notes, some people I've talked to have used just on their phone and app. I use Evernote. I really like that. Or, you can use a text document. I'm not an iPhone person, but on the iPhones, I guess they have their own note recording thing. You can do a voice text where you're doing your HPIs at least that way, and copying, pasting.
 

Did you like this video? If so, hit Like and Subscribe, and share with your NP friends so together we can reach as many new grads as possible, to make their first years a little bit easier. And don't forget to sign up for the ultimate resource guide for the new NP over at realworldnp.com. You'll get these videos sent straight to your inbox every week with notes from me, patients' stories, more helpful insights and bonus content that I just don't share anywhere else.

Definitely leave me a comment below in this video. What are some of the time-saving hacks that you're using in your primary care practice? I'd love to hear them and so your other NP colleagues who come and watch these videos as well. And if you'd like that cheat sheet of quick tech templates that I use, it's not comprehensive but it's kind of a sampling of the things that I use, and if you like it, definitely let me know. But you can download that here. Thank you so much. Hang in there, and I'll see you soon.