Guest blog post by Jessica Reeves, MSN, MPN, APRN: The World’s Most Productive Nurse Practitioner
Carol’s first appointment was at 8:25; she arrived at 8:45.
She took a few minutes to settle in, hang up her coat, turn on her computer and log into the EHR. A nurse knocked on her office door; the pharmacy was on the phone, and their records show that the patient she saw yesterday has an allergy to amoxicillin. Did she want to change the prescription for Augmentin to something else? Logging into the patient chart, she notes the allergy for amoxicillin was listed because the patient once had diarrhea after taking this antibiotic. Okay, go ahead and fill the prescription as is; it’s not a real allergy.
While the nurse is in her office, Carol asks whether the records were ever received for that new patient that is on her schedule for this afternoon. “I can check and get back to you, I haven’t seen them,” the nurse says. They get into a conversation about how long it takes to get records from other offices, and how things keep seeming to get lost around here. She is reminded of (and retells) a story from back in the day and how a delayed chart caused a whole bunch of commotion and confusion.
It’s now 8:55. As the nurse excuses herself (the pharmacy is on hold, after all), Carol clips on her name tag, slings her stethoscope around her neck and heads into the exam room to see her first patient. 30 minutes late.
The patient is in for a three month diabetes follow up. But since her last visit, the patient has started to have some shoulder pain, and it’s become really bothersome. Investigation reveals that the patient has been carrying a heavy bag on her shoulder and sleeping with her arm over her head. Some days she can barely move it, but most days her ROM is limited. It’s not too tender, but her ROM is definitely compromised, especially compared to her other shoulder. The patients works in a daycare, and because of this shoulder pain, sometimes has trouble lifting the toddlers up, which is interfering with her work. The patient needs a referral to PT but also a note for work that she shouldn’t lift more than10 lbs while she is being seen by PT. A prescription for a short course of muscle relaxants and some voltaren gel is also a good idea.
They review the labwork for her diabetes and discuss increasing the dose of metformin. While looking for the labwork, Carol notices that this patient is due for a urine microalbumin. She brings the patient over to the bathroom and tells her how to go about leaving the urine sample. She plans to meet the patient back in the exam room to finish up, but on the way gets snagged by one of the secretaries; the 8:50 patient is threatening to leave because they’ve been waiting so long (it’s now 9:25), and her 9:15 patient is also waiting.
The first patient comes out of the bathroom, and Carol takes the urine sample and walks it over to the lab area. She returns to the exam room with the patient, who realized while she was in the bathroom that she’s also been experiencing what she thinks might be a yeast infection – she sure is itchy down there, and the monistat she got at the store doesn’t seem to be working.
Carol asks the patient to remove her shoes so she can take a look at her feet; the patient states that she has been very diligent about wearing shoes in the house (or at least a slipper with a firm sole), and she hasn’t noticed any changes in her nails or skin. Does she really need to take her shoes and socks off? It’s hard to get her compression socks back on, and she might need some help because of her shoulder pain.
A glance at the clock reveals it is now 9:35.
This 8:25 patient is running way over (although the patient arrived on time), the 8:50 patient is getting upset about having to wait, and the 9:15 patient has arrived but is still in the waiting room because there are no available exam rooms to put them in.
If Carol’s day starts like this, it’s fair to assume that it will continue like this, and also fair to assume that she will be here late tonight trying to get through all of her charting – to say nothing of her inbox.
. . . . .
What went wrong here? More importantly, what could have been done differently to make things run more smoothly? Let’s take a look.
- Carol arrived late. This is the first domino to fall, and it’s all downhill from here. If she can find a way to arrive on time (or even a few minutes early) and start her day on time, it will improve her morale and that of her colleagues, and keep patients happier.
- Too much chit-chat with the nurse who had the pharmacy on the phone. It’s important to develop a relationship with other staff, but not when you start your day by arriving 20 minutes late. And as for those medical records for the patient on the schedule this afternoon? Worrying about it now is just a waste of time. Suppose the patient doesn’t show up; you will have worried for nothing. Suppose the patient does show up: do what you can in the visit when you are face to face with the patient and take care of the rest after the fact – it’s out of your hands at this point.
- Carol went into the first patient even later than she needed to. Arriving 20 minutes late is bad enough; why make it worse by not going straight into the exam room? Taking those extra minutes to settle in left her open for an interruption from the nurse with the call from the pharmacy.
- Got off-topic. A diabetes follow up turned into a diabetes follow up PLUS shoulder pain (and possible yeast infection). Should Carol have talked to the patient about her shoulder and possible yeast infection? Yes. But she should not have been taken by surprise by these concerns. If she had set an agenda with the patient at the beginning of the visit (“What’s on the agenda for today?”), she would have an idea of what she needed to cover in the visit and been less surprised by these two add-ons.
- Got off-task. An assistant or a nurse should have gotten that urine microalbumin. Ideally, there should be a work-flow protocol for standard visits (like a three month diabetes follow up), and the person rooming the patient should know to check and see if the patient is due for this routine lab. If it was discovered during the visit, as was the case here, Carol should have made note of it and asked an assistant or nurse to collect the urine from the patient – after Carol was done with the visit.
- Added tasks. Writing a note for the patient’s employer is not a huge task, but it is another log on the fire. There may not have been a way to prevent the need for this, but if all of the other things that contributed to running late had NOT happened, this would not be such a big deal.
- Poor planning. As mentioned previously, rooming staff should be trained to look at the reason for the visit and know that a diabetes follow up should have their shoes off before the provider enters the room. There should have been a flag to let the rooming staff know that this patient was due for a microalbumin. If Carol entered the room with the patient prepared to have their feet examined – which should be a part of every diabetic follow up visit – it would contribute to the visit, and session, going much more smoothly.
Are you a Carol, or do you know a Carol?
Jessica Reeves, MSN, MPH, APRN is a Nurse Practitioner and coach based in New Hampshire. She is also the author of Secretes From The World’s Most Productive Nurse Practitioner (available wherever books are sold). Learn more at www.ourcoach.online or email her at worldsmostproductivenp@gmail.com
For more tricks and tips on charting and time management, check out The Time Management and Charting Tips Course.
For time management and charting tips, check out The Nurse Practitioner Charting School– The one stop for all documentation resources created specifically for nurse practitioners. Learn more at www.npchartingschool.com
**Full disclosure, this blog post may include affiliate links. I do receive a commission if any of the affiliate programs/services/supplies are purchased. This is at no extra cost to you but does allow me to continue to provide content as The Burned-out Nurse Practitioner! Thank you!
**Full disclosure, this blog post may include affiliate links. I do receive a commission if any of the affiliate programs/services/supplies are purchased. This is at no extra cost to you but does allow me to continue to provide content as The Burned-out Nurse Practitioner! Thank you!
