EP 9: Your First Clinic Day Playbook—Set the Tone for Success

This episode of NP Launchpad focuses on how to successfully navigate your first day in clinical practice and set the tone for your career. The hosts share practical strategies like pre-visit planning, mastering electronic health records, and using daily huddles to improve workflow, safety, and patient care. They also emphasize building meaningful patient connections, managing time effectively, and handling common challenges like running behind or triaging multiple concerns. Throughout the episode, listeners gain actionable tips to feel confident, prepared, and supported as they step into practice.

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Transcript

Voiceover 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico-Denino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Vanessa Pomarico 0:34

Hi everyone, and welcome to the second season of NP Launchpad. My name is Dr. Vanessa Pomarico, and I'm the lead for this episode of NP Launchpad. Today we're going to discuss the first day of the clinic playbook, and this is where you're going to really learn some tips of the trade on how to make that first day run smoothly and how to set the tone for the rest of your career. I'm delighted to be joined today by my friends and co-hosts, Dr. Jason Gleason and the soon-to-be Dr. Chris Gleason. Welcome, guys. It's nice to see you both again. Good to see you.

Jason Gleason 1:07

Vanessa, I I have to ask you if you notice something different about each of us since our last episode.

Vanessa Pomarico 1:14

I I I actually did notice a little a little difference in the facial hair hair.

Jason Gleason 1:19

Look at this baby face Christopher now, right?

Vanessa Pomarico 1:22

Very handsome. Is this like a thing?

Christopher Gleason 1:24

No, it's I had army drill this weekend, so I had to shave for it. Yes. Yeah. Once the book I have to do it whether I like it or not.

Jason Gleason 1:31

And mine, I have to tell you this, Vanessa, because you've never dealt with this issue. When you're shaving as a guy, if you screw up, you got to shave it all off. Right? So I messed up, but now I have this nice porn stash. And you know, it might be good for not only fans, but homely fans. Not only fans, but homely fans, because I look very homely. Oh my word.

Vanessa Pomarico 1:51

No, I think it looks great.

Jason Gleason 1:52

Here we are. Awesome. I'm so excited to be with you again.

Vanessa Pomarico 1:56

Well, today we're going to talk about the first day on the job. And, you know, we've all been there. The three of us have been there on more than one occasion on that first day on the job. So for our listeners, we're really going to talk about how you've already wowed the employer because they've already hired you. And now we're going to talk about how to make that all-important second impression of that first day. So a couple of housekeeping things I want to take care of before we get started. Just remember to email any of your questions to nplaunchpad@fhea.com, and we may answer some of your questions on air in a future podcast. And remember, as a disclaimer, that we are here mostly for education only, as a friend, as a colleague, and not for legal or any clinical advice. So let's dive into our hot topic discussion today. What are our pre-planning tips for the very first day of practice? How do you show up getting ready to hit the ground running? You know, I know that that first day is always stressful. Um, you know, I always equated it to that first day of school. But with our pro tips, we know that you are all going to rock that first day and leave a really great impression. So one of the things that I always tell my students about when they're, you know, getting ready for that first day, not just for clinical, um, but for the new nurse practitioners on the job, is you can't really make that second first impression. So it's really important that you set the tone for a positive experience. And it's not unlike the first day of clinicals, right? We all tried different clinical rotations. And so we had to make a first impression every time we went into a new clinical site. So it's really important to get there on time, make sure that you get there early, know the lay of the land, and be ready to hit the ground running. So some of the things that we can think about are if you have the ability, is to preview the schedule ahead of time. If you, if you have access to the electronic health records, maybe doing some chart review planning the night before to kind of help you get acclimated with electronic health records. Um, some people may not have the ability to do that. So, in that event, I would tell you if you're still on paper charting or you don't have access to home access or remote access for electronic health records, maybe go into the office a little bit earlier. I don't know about you guys, but I don't really advocate that we have to spend a lot of our own personal time documenting or prepping the next day. No. Right. But, you know, in those early days, you may have to spend a little bit of that time to kind of prepare yourself. What do you think about that?

Christopher Gleason 4:34

I I agree, Vanessa. And I also think that, you know, previously we had talked a little bit about shadowing prior to even like accepting the job. And I think, you know, doing a day of shadowing just before that first day, get that clinic flow, get a better understanding of of what you're kind of walking into. I think that's a great, a great idea.

Jason Gleason 4:50

Absolutely. Yeah, be prepared ahead of time. I would even say before you even take a job, during the interview process, I would ask those that you're interviewing with, hey, can I spend a day with one of your colleagues, right? To see how the flow is and and just uh to really look at things. You may even find out that you may not want that job in that facility or that you really love it. So yeah, being prepared ahead of time, I think is important.

Vanessa Pomarico 5:12

So, Chris, what are some things you you would advise people to do, you know, as part of their preparation? You know, like maybe like what do you think they should look for in the chart?

Christopher Gleason 5:21

Um, one of the things that you should really be reviewing is their medications. Um, I remember when I was going through uh my master's degree, uh, one of my instructors said, if you review their medication list, you know their diagnoses. And that that's been, you know, that's been proven true throughout my career. So I think one of the main things to look through, look through their diagnosis, look through their, look through their medications, get an understanding of their labs, you know, if they if they have dia uh diabetes, what was their last A1C like? If they have, you know, chronic hypertension, what is it what have their blood pressures been running, you know, getting and get an average and an understanding of those.

Vanessa Pomarico 5:57

Right. And, you know, one of the things I find I do as well is um I always always look under uh imaging because, you know, maybe somebody doesn't necessarily have like a thyroid diagnosis, but maybe in the past, either before me or I might have seen them, um, they might be due to have a thyroid ultrasound, or maybe they might have had some abnormal LFTs in the past and I might have done a liver ultrasound and maybe they had fatty liver, and maybe it's time to um repeat that as well. So it's always a good idea to kind of click through a lot of different things after you've done the meds, is to look at some of that imaging and but also too, maybe looking at any outstanding referrals. I know that I feel like I spend a good majority of my day doing referrals, right?

Jason Gleason 6:45

Yeah, absolutely.

Vanessa Pomarico 6:46

And then how many, how many patients, like you do these referrals, they say, Oh, I need a referral to Durham, I need to see GI, you know, I'd like to see somebody about weight loss medication, and then you put all these referrals in, and then they come back a year later and they haven't even followed up on any of them.

Jason Gleason 6:59

Right. Absolutely. I changed my mind that they didn't need to do that. That is beyond frustrating and happens on so many Yeah, it does so many cases.

Vanessa Pomarico 7:07

Interestingly, you know, those referrals, when though patients don't follow up on the referrals in a legal world, if a patient is diagnosed with, let's say, colon cancer a few years later and they didn't follow up on it, you know, that then turns back on to us, which I think is is not really fair because where's the patient responsibility on all this?

Jason Gleason 7:28

Yeah. Absolutely. Absolutely. But until we close that door and make sure that they had the follow-up, you're right. Yeah. Right. Yeah, we definitely own it. You know what, you know what I do to make sure, and I think I meant might have mentioned this in a previous episode, but what I what I do whenever I refer a patient is I'll put them down for like at least a phone visit and may and I'll project it. Like if I'm referring them to GI, you know, in our community, they usually get it in about four to six weeks. So I'm gonna call that patient in about eight weeks. So I put them down for a phone visit so I don't forget to close the loop and check in with them. Hey, did you get into this, this specialist? And often, like you said, you know, well, I changed my mind or the specialist went on vacation, I couldn't make the appointment. Or they or they did, or they did make that. And then I document that in the chart. I think it's so important we close the loop on our referrals.

Vanessa Pomarico 8:12

That's a great idea. You know, I never thought about doing something like that. I I think because my schedule is already so overloaded, I don't know where I get these. Oh, yeah. You know, but but again, you know, you guys work for the VA, you have a little bit more flexibility with your schedules, unlike what I do, you know, out in my world. Um but but you're right, you know, the screening reminders are a great idea. And, you know, there are other ways that you can do that in the electronic health record. So you really have to kind of look at what's gonna work for you. Um, and then what are the the other things that you think about in terms of like what are your must-do? What's on your checklist um for things to do for your patients? Things like safety issues or red flags, that kind of thing.

Jason Gleason 8:53

This is gonna kind of sound, I guess, a little bit different because it's not clinical based, but I I found it so important and patients will love you for this. You'll put such a great connection with them because I really believe in connecting with our patients, empowering them, and then inspiring them when they leave our offices. And one way that I connect with them, as I mentioned previously on an episode, was you know, talk about something that's not even medical related. How's your family? How's your dog? Whatever. But it's impossible for us to remember all those details between appointments. So here's what I do. Here's a tip for our listeners out there and our watchers, if you're watching this on YouTube or other or other sources. At the very top of every progress note, I put this in big capital letters, connection point. And by that I list something unique about the patient. Their daughter just got married, they got a new pet, their dog died, perhaps, you know, they got a divorce. They're they love going to Europe. Some kind of connection point. It doesn't have to be big, just a sentence, connection point at the very top of your notes. And then uh and then some kind of way you're gonna connect with that patient so you remember what to ask them about. So I I find that's really helpful and and it it really is helpful and and be genuine about it, right? You're not just right going through the motions, but yeah.

Vanessa Pomarico 10:00

No wonder your patients love you.

Jason Gleason 10:02

Well, I and I pay them good money each time too. I have, you know, write everybody a check.

Vanessa Pomarico 10:07

So I don't I don't have a space to write connection issues on my particular electronic health system, but what we do have is a sticky note. And there's two different sticky, yeah, then there's two different sticky notes. There's one in yellow and then there's one in blue. And the one of the the one in yellow is if anybody opens up the chart, it's a sticky note that will say, like, so for my particular patient population, you know, I put in there, uh, be sure to call the patient by patient, you know, what are their chosen pronouns. Um, or if it's something that I want just only I can see, but it's my connection point, is exactly what you said. You know, maybe their significant other was sick, or I have a patient that doesn't want to be asked about her mental health issues unless it's during her physical. Oh, interesting. And so, yeah. And so I put that on my private sticky notes. So I love that connection point. I think that's such a great idea, Jason.

Christopher Gleason 11:01

Yeah, thank you. Um I think it's important. Oh, sorry, V. Go ahead.

Vanessa Pomarico 11:05

No, go ahead, Chris.

Christopher Gleason 11:06

Um, I think it's important too, because sometimes during those initial conversations is when you find out the kind of the deep down medical diagnoses. I know, you know, recently I was talking with a patient. It was a new patient that I had, just getting to know them and talk about medications, talking about past medical history, and they happen to mention that their father had a hit had um prostate cancer, which is huge because especially if you're dealing with male patients, you're gonna want to know, you know, what's a what their PSA levels are. You're gonna want to you're gonna wanna track and trend those. So during those initial conversations, you could really find out those those kind of key characteristics about their past medical history, especially if you delve into, you know, into their history and and express a genuine interest in in their life.

Jason Gleason 11:46

Absolutely.

Christopher Gleason 11:47

Yeah.

Vanessa Pomarico 11:48

And you know, the I guess the bottom line or the the sticking point with all of this is to make sure that you get to know the patient before you get to know the patient, right? Like don't pretend that you know what you don't know.

Jason Gleason 11:59

Right.

Vanessa Pomarico 11:59

And don't walk in there so that the patient doesn't feel like you never took a look at their chart.

Jason Gleason 12:05

Right.

Vanessa Pomarico 12:06

You know, because they're gonna know, they're gonna say, Well, isn't everything in there? And sometimes I'll say to the patient, you know, I'm looking through things and I'll say, you know, I don't see your last colonoscopy. When was the last time you had one? And they'll say, well, you know, isn't it in that that computer there? And I always say to them, listen, this is not a crystal ball, not everybody's on the same electronic health system. That's right. Yes. You know, and so I don't have right, I don't know everything. And so that's why I'm asking you so that this way I can then contact your provider and find out. And I keep a real sticky pad on my computer desk in the office, and then I write down the things that I say. And then this way when I walk out, I can just hand it to my medical assistant and say, call Dr. So-and-so's office and get the last PSA or get the last colonoscopy or the last CAP or whatever it is. So it just that'll give you the the patients will just feel a lot more secure if they find that you're really taking a genuine interest and you're not trying to just muddle your way around it because they're gonna see right through it. Yeah.

Jason Gleason 13:03

Absolutely. That's so helpful. You know, you know what I do too before I go in the room, because every every clinic is different, every system's different, right? So some of our listeners may experience this, others may not. But at the VA, you know, we have computers and yeah, we should be taking the laptop in the room, but a lot of our providers don't do that. It's cumbersome and it it's really time consuming. So for us, what usually works well for most of our providers is we have workstations in a big area where all of us are grouped together, and then we go into the room to see the patient. And before I go in the room, I'll look at the labs, you know, write those down on a little sheet that I have that the nurse has already writ wrote in the written down the vital signs and everything. But I'll look at the labs, I'll look at all that stuff, review their meds, go into the room. And what you said is exactly right. The one about not knowing the patient before you get in there, because I'll tell you what, that's gonna happen to every single person out there working as a healthcare provider at some point. You go in the room because and usually when I do that, it's because I'm rushed and I didn't have time to look at that chart before, or I'm behind on my schedule. So take the time. I can't stress that enough. That was such a good point. Can you say that again for our listeners out there? Uh know the what was it was know the patient before you know the patient.

Vanessa Pomarico 14:10

Know the patient before you know the patient and don't pretend you know them because they're going to see right through you.

Jason Gleason 14:15

They absolutely they will. Yeah, definitely.

Vanessa Pomarico 14:18

And you know, that that kind of leads into the next point about doing our daily huddles. I don't know if you guys do huddles, you know, at the VA, um, but we do huddles in the morning. Our uh manager will get all of the medical assistance and then kind of talk about things, and then each one of the MAs will come to the providers and then we just briefly go over our patient, you know, schedule for the day and have a little discussion about, you know, who do I need to be worried about today? Like, you know, I have some patients that'll say, you know, um, somebody will come in and they don't want the medical assistant to take their blood pressure because they know that as soon as they come in, it's going to be high. So I'll say, don't take their blood pressure, or if somebody doesn't want to get weighed, I'll say, so-and-so is really sensitive. So don't tell them what it is, have them turn it around, don't announce it, and don't put it in because, you know, some of the rooms the patients can see are screens. I'm lucky enough that I have a workstation in each one of my exam rooms. And so I tell them don't put the weights in until after I've gone in with the patient. This way they won't see it being entered in there. So the huddles really are so important. And it only takes about five minutes, 10 if you have a really extensive schedule. Um, you know, I then like if I'm working with somebody new, I'll have to say to them, you know, the the 10 o'clock patient always vasovagals every time we do a lab draw.

Jason Gleason 15:35

Right, right.

Vanessa Pomarico 15:36

So if you draw their blood, you're gonna need to draw it in the exam room because they're going to vasovagal. So have everything on board for them, you know, before you even draw the blood. So yeah. So I think huddles are so important. Um, and then, you know, uh safety basics, you know, we always have to think about chaperones. I don't know, do you do you both see a variety of patients or is it primarily just male or female? I'm not sure how things work about. A variety, yeah.

Jason Gleason 16:02

Yeah, you know, I'm so proud of the VA because women's health has really been on the back burner for decades, not just at the VA, but everywhere, right? It's not a priority and it's so important. And the VA has dumped millions of dollars into prioritizing women's health, which is fantastic. And and so, yeah, so there are instances where we we would need a chaperone to come in the room and a huddle would be a great place to plan that out. Right.

Christopher Gleason 16:23

The other aspect of it is too is the um the VA has actually been really good with um LGBTQA plus healthcare. The um they have we we have what we call VCC, which is our veteran care coordinators, and they actually, you know, they're the go-to for the for the for this type of healthcare. Or, you know, if you're if you're dealing with um our trans patients or anything like that, they're they're the go-to for it. So they can give you the resources that you need, all of those things. So yes, when you know, when we're going through our our day, our list of patients, you we do really we really do have like a plethora of patients to go through. And I agree with you. I think the you know, the huddle in the morning is so important. I huddle with my RN, I huddle with my opium because I want to know their input on these on this patient because they're we're all three of us are gonna have different aspects to to kind of touch on for each patient. So I think it's really, really important.

Jason Gleason 17:09

The other thing that I find really helpful in the huddle is sometimes you look at your schedule and you'll see a patient on there that was added on there late in the afternoon the day before for like chest pain. It's like, what are you waiting for to see me for chest pain and primary care? Go to the ED. Exactly. So it's a big safety issue too, right? Yeah, yeah.

Christopher Gleason 17:25

Yeah. And then you get um, I actually had one today. I had a phone visit that was scheduled for me. The uh the veteran had lost a crown and they scheduled the phone visit for me. I don't know what they expected me to do with it, but that's what they did. Yeah, it's interesting.

Jason Gleason 17:38

So it allows you time to scrub your schedule. Yes, absolutely.

Vanessa Pomarico 17:42

Right. Yeah, you know, it's Chris. I I have to tell you, there, I don't know about where you guys are, but in Connecticut, I don't think there's a dentist that works on a Friday. And so I always get these phone calls on a Friday, and they say a patient has I I have a dental access. Okay, well, I'm not a dentist. You know, call your dentist. I can't do anything about that.

Jason Gleason 18:00

Let me get my pliers out, meet me in my garage, right?

Vanessa Pomarico 18:02

No, come on. Exactly. Exactly. Um, and so so uh these are just so many really helpful, great points. One of the things I just want to touch on real quick is um you have like security protocols in place. What do you do if you have a patient who becomes combative or belligerent? Do you have like panic buttons in your rooms? What you know, what do you what systems do you have in place?

Christopher Gleason 18:24

So we have we have uh panic alarms in our in our um patient rooms. And actually they just switched it. So we used to have just physical buttons that you could push, but they recently switched it. So now we press two keys on our on our laptops and then it it rings in and it rings the panic alarms and it tells people where you're located.

Jason Gleason 18:41

To check with your clinic wherever our listeners are gonna be working and find out definitely what the system is. What what system do you have, Vanessa?

Vanessa Pomarico 18:49

None. Um scream for help. Yes. Yeah, uh pretty much. And and the the sad thing is that I work in a basement um and and the and I've been asking for all the time that I've been there because I've had patients who have gotten um belligerent, patients who have come in impaired. Um and I've and I'm a pretty tall person. Um and you know, my hair kind of intimidates people. Um, but uh I've still had patients who have uh gotten a little bit physical with me and um it's really hard. So now what we do, um I have a signal with my medical assistant that I'll I usually will just say to the patient, excuse me, I just want to call my MA and tell them I'm running a little bit behind for my next patient. And when I say that to my MA, please let my next patient know I'm running behind and they know that I'm not. Um then they know that it's time to call security and they need to stand outside my door. Or conversely, and it doesn't happen a lot, I don't want to scare our listeners. Um, but the other times that I've I've had patients on the schedule that I know might be um a little bit difficult, I'll say to my medical assistant, you're staying in the room with me. And then I have somebody else on standby on the outside because we have to know when to call 911. And fortunately, uh the police station is literally a block from my office. So um they come very, very quickly. So sad that we have to think about those kind of things, but it's important to ask these questions when it's on your first day on the job is to find out about who does who does your chaperones. Is it anybody that's available? Who what are your security protocols and and how what how do I handle this if there's nobody in the room with me?

Jason Gleason 20:33

Okay.

Vanessa Pomarico 20:34

So great, great points.

Jason Gleason 20:36

The other time I think it's so important to have a chaperone, you know, not just during like annual physical exams like women's health, for example, or a prostate exam in a male patient. But um, I'll look through the chart and if there's any history whatsoever of any sexual trauma in their past, even if I think like, and it's to protect ourselves in part, right? To bring a chaperone in the room, but to make the patient more comfortable, you know, to bring uh and usually it's some a member of the same sex in the room with them when even if they're there for a cold or a sore throat or something, just always to have another person there just for the patient's comfort, I think is really important that to promote safety and just that environment where they can be safe.

Vanessa Pomarico 21:13

Right. One of the things that I do, especially for um my trans patients, but also those patients who have had sexual trauma, um, is that I actually tell them I don't ever do an intimate exam the first time I meet them because I think there's so much that they need to really get to trust me. But one of the things I will suggest is that when they come back for that intimate exam, as I'll say to them, feel free to bring somebody with you, a support person, unless you want my medical assistant. And many of them, once they get to know my MA, they're very comfortable with my MA being in the room. But I always tell them bring a set of headphones, um, you know, do whatever it is you need to do. I actually had one patient that their BFF lived out of state, but they were the per they were their person and they FaceTimed. And I had to actually find out was it I don't know if we can FaceTime doing a sensitive exam.

Jason Gleason 22:04

Right.

Vanessa Pomarico 22:06

But that's what we did. And so my medical assistant was in the room facing the patient and had the phone facing the patient while I was at the other end doing the pelvic exam. Um, but it it got the patient through it. So my pay my medical assistant was able to hold their hand, hold the phone. Wow. Um, and we were able to get through it. But it's really just find out what you can do to make the patient comfortable, and then that's how you work through it.

Jason Gleason 22:27

So how nice we consider you that that's truly the magic of what we do as professionals, as nurses and NPs, right? That that is so good. I'm gonna use that idea with my patients coming up. Yeah, that's very good.

Vanessa Pomarico 22:38

I love that. Um, one of the other things we need to think about too is about standard flow, making sure that you get into a routine every day. Because if you don't get into a routine of asking things like in the same manner, in the same ordering, then you can start missing things. And one of my biggest peeves is the last menstrual period status. I have when we get floats that come through, I inevitably I'm grateful that they come in and they they check my patients in. But I'm always amazed, like, why are you not asking when the last menstrual period is? Because if I have to prescribe medication, I need to know this. Yeah. So it's really anybody who's of childbearing age, whether or not you think that they could be pregnant, don't assume that and don't assume that, especially with trans patients, that they aren't considering pregnancy. You have to ask everybody about that menstrual status. But also things like anticoagulants, you know, any of those high-risk meds where you're going to have that interaction, those interactions of other medications, you need to know all that. And um, and electronic health records, again, we're very lucky that, you know, when you prescribe a medication, usually an alert will pop up. But even still, you can't always count on a computer to do that brain work for you.

Jason Gleason 23:51

Right? Right.

Vanessa Pomarico 23:53

So one of the things I want to ask you in the VA, what happens when there's um critical lab results that come back? You know, I I know that you guys don't take call at night, but what happens with those labs? Let's say you you order labs on a patient and something comes back critical overnight. Does anybody get called on it? Or do you have to wait till the next day?

Christopher Gleason 24:13

They do. So what happens in our uh in our situation is there's a a doc that's on call or a provider that's on call at Fort Harrison, which is uh kind of our main campus, and they're alerted to the critical labs, and they'll contact the patient and give them what you know the next best step sort of thing. And it's interesting too, because living in Montana, we're very rural, obviously. We have a lot of Seabox, so they're community-based outpatient clinics, so they in the outlying areas, so and the these uh providers will cover all of those Seabox. So any of the patients that come in with a critical lab value, uh they'll reach out to them and and tell them, you know, what the next steps are.

Vanessa Pomarico 24:49

Nice. And so as a new person, oh go ahead.

Jason Gleason 24:53

Oh, I I was just gonna say, you know, the VA is the industry leader. It really leads the way in so many new concepts and uh innovations and technologies. I'm so impressed. And you bring this up after hours and contacting the emergency provider, whoever's in the ED of the physical site, but the VA actually had now has teleemergency medicine. So if a lab values off or if there's an emergency and they can't get a hold of somebody, they they're always available, which is fantastic. And then they'll triage the patient, tell them to go to a physical on-site, you know, ED for treatment or somewhere else. But and then we'll just follow up with them the next day usually.

Vanessa Pomarico 25:27

Nice. So again, these are the things you need to think about if you're not working for the VA, who's gonna be that person if you're gonna be the person on call. And I really don't recommend that new people take call without having backup. Oh, you know, because you know, you will get that phone call at two o'clock in the morning with a critical value and then go, what do I do now? So you have to have that. Yeah, it's frightening, right?

Jason Gleason 25:51

It is, it is.

Vanessa Pomarico 25:52

You know, I remember the first time I got a potassium back that was like nine, and I'm thinking, uh I don't know, is this is this? And it wasn't even a patient of mine. Um, and we didn't have electronic health records. We were still on paper charts at the time. So you have to have that backup, you know, that those first many months that you're gonna be taking call.

Jason Gleason 26:10

So and always keep in mind that the the ED is your ultimate answer, right? If you added nine on a potassium and it's two in the morning, you're like, oh, where do I send this patient? What do I do? The ED is always the best choice. And obviously you want to be smart about it, not overwhelm them, right? But yeah, yeah, I think it's such a good point.

Vanessa Pomarico 26:27

And so, yes, the the the answer to that question that you're saying, well, do I call the patient at two o'clock in the morning with a critical value? When you pull up the electronic health records and you look through it, if it was your patient, you're going to know, you know, yes, I've woken up patients at two o'clock in the morning to say, you know what, your INR is off the charts. You need to get to the ED now. You know, this could be life-threatening. And so you you need to go down and then, you know, put your message in the electronic health records. So when they get to the ED, the ED will know why you're sending them down there.

Jason Gleason 26:57

It's interesting. I had one patient that was in the middle of eating breakfast in a diner, and I get a call from the radiologist. And this is thankfully in the morning, and he had a subdural going on like right then. And it's like, and I and I call the guy, hey, how are you feeling? Well, I'm good. I'm trying to eat my hash browns. It's like, well, you know, we need you to go back to the hospital. I'm sending an ambulance, so hurry up and eat your hash browns, right? Yeah, but you never know, right? You never know when it's you just don't know. No, no. You know, one last thing. Oh, go ahead.

Vanessa Pomarico 27:29

I was just saying, it's not like we send everybody to the ED. So you're right. Like I said, the ED is your friend, right?

Jason Gleason 27:34

Mm-hmm. Yep. Yeah, treat them well, treat them well. You know, one last thing about flow that I would suggest um our listeners really get a good grasp on, especially for that first day. It's so important for proper flow is to make sure you give yourself adequate bathroom breaks. You got to promote that flow, right? The flow. Right.

Vanessa Pomarico 27:56

Both ways, not just workflow, but your own flow.

Jason Gleason 27:59

That's right. That's right. Your own flow. So take care of your own flow. Make sure you have time because there are days where you may not find any time. But most of our listeners already know that because they're working in hospitals or acute care as nurses.

Vanessa Pomarico 28:10

Right. But it's you have to remember you can't take care of anybody else if you don't take care of yourself. So make sure that you're hydrating, that you're eating or eating small snacks during the day so that you're you're staying, you're keeping your glucose up, but it's it's important that you're doing your own, your own care while you're taking care of your patients.

Jason Gleason 28:30

Keep things for what it's about. Absolutely. Yes, indeed.

Vanessa Pomarico 28:34

All right. So let's move on to the electronic health records. And Jason, I'm gonna tack into you because you're like our resident techie here. But you know, we talk an awful lot about, you know, knowing what your logins are, and there's always a million of them. I mean, we have to think about our electronic health records, and like every 12 weeks you have to change it, and it can't be the same one, the same password you've used before, any of your prescription drug monitoring, your lab portals, your imaging, all that secure messaging. What's your suggestion, Jason, on how to build your favorites, you know, like your labs, et cetera? What what is your suggestion for all that?

Jason Gleason 29:08

So to build my favorite logins or to uh you well, your your logins, how do you remember all of your logins?

Vanessa Pomarico 29:16

And then um, what is your how do you build your favorite for you know your favorites um for all of your labs and your imaging and that's the right thing.

Jason Gleason 29:23

Oh, for like orders. Like for order sets.

Vanessa Pomarico 29:25

Yeah, I'm sorry, your order sets, yeah.

Jason Gleason 29:26

No, that's all right. No, yeah, you know, most EHRs out there like ours at the VA have that option, and it's all about knowing ahead of time. Like during your first few weeks of getting out there and practice, I'd really spend the time, even if you have to stay over for a few hours, you know, during the week, just to learn your EHR system because it'll be your friend, it'll save you time in the long run. If you can build those order sets, because it's much easier to order a panel for somebody with diabetes that comes in that's a new diagnosis where you get all the labs ordered by the push of a button instead of having to order each of them individually. We often do that at the VA. And remembering passwords, it is a pain in the butt. Thankfully at the VA we have cards, security cards that we have, cat cards that are are are secure, and we use those to log in and off of our computers. Many places have those. ID badges and the like. But uh, but yeah, if if I forget my password, you know how what a pain in the butt that can be. You have to call IT and have it reset, and that just takes a lot of time. Right.

Christopher Gleason 30:21

Kind of a little bit on what you were saying with order sets. I think it's also important to, you know, we've touched on this in previous episodes about dot phrases. Oh yeah. That first week that you're there, get to know your EHR, but also create dot phrases. It'll save you so much time in the long run. And and sometimes you can, you know, predict those dot phrases, create those order sets, and then you're good to go. You can hit the ground running.

Jason Gleason 30:41

Yeah.

Vanessa Pomarico 30:42

Great idea. So what about contact lists? I mean, you guys, you know, you're like the two princes of of uh the VA here because you get to work with registered nurses and LPNs. Um, but how about like keeping a contact list? Do you have any suggestions about things like, you know, who your supervisors are, your referral coordinators, your IT support people? What do you what do you suggest about that?

Christopher Gleason 31:05

I think that's very important. And I also think it's very important to keep a good rapport with those people. You know, we in the VA we have um PAC pharmacists that we interact with. And it's it's crucial to have a good a good rapport with them. We have social workers that we interact with, we have, you know, other providers that we interact with, nursing that we interact with. And it's so important to keep a good rapport with them, but also to keep uh a list or um at least an email of contacts, you know, who do you who do you look for for radiology? Who do you look for for um you know nephrology and all those other contacts?

Jason Gleason 31:36

Well, and what I would do is, you know, I mean, back in the day before all the electronics we have now, you know, you'd write it down and you'd laminate it, keep it in a desk store or something. And then the minute you do that, then all the contacts would change, right? But uh, you know, I I usually keep it in like the notes app on my phone, you know, contacts, a list of folks to reach out to. But here's a good tip for our listeners when you're creating that list as a new NP in the community, when you're creating that list of contacts, don't just write the name down, but just briefly send them an email, call them, say, Hey, I'm I'm new to the community. I just want to introduce myself and thank you for such great services that you're offering everybody. My colleagues rave about you, you know, some kind of nice email just to make contact with them because that'll go a long way. You'll know who your friends are, right? Yeah, so make friends from the beginning. So not only make the list, but make the connection, you know, with with the people you're gonna interact with as much as you can. As much as you can.

Vanessa Pomarico 32:26

That's so true. All right, so let's talk about you know, that I'm behind without panicking. How do you handle that? Who who when do you send up the the flag to go, I need help?

Christopher Gleason 32:41

No, that's when you go into the patient room, you close the doors, and mind you, you're in the patient room alone and you just scream. Yeah, and then you exit the patient room.

Jason Gleason 32:47

The soundproof patient work. Exactly. And sometimes we even need pads on the wall, you know. Yeah, a padded soundproof room. At the clinic, we we all often joke that we're gonna get a rage room where you can go in with a bat and destroy, you know, television sets and things to release your stress. Wouldn't that be nice?

Vanessa Pomarico 33:03

I would love that. Wouldn't that be nice?

Jason Gleason 33:05

Who needs a counselor when you have a rage room?

Vanessa Pomarico 33:07

Right? I I think I said it earlier to Chris today. I said, I'm gonna take a hammer to this thing. Um, wouldn't that be nice if we did have a rage room? Absolutely. So one of the things that I do when I start to get behind is um if I see that I'm I'm running a little bit behind, I usually will excuse myself from the patient room because I don't want them to feel bad if I if they hear me on the phone saying I'm running behind because then they're gonna say, Oh, I gotta hurry up. She doesn't have time for me. I'll say, excuse me just a minute. Um my team, my team is buzzing me, and I'll I'll blame it on my phone or my watch that they're trying to get a hold of me. And I'll just go out and I'll just say, Listen, I'm running behind. Tell my next couple of patients I'm running behind. This is obviously not my safety issues. This is when I'm bona fide running behind. Yeah. Um, but then, you know, I have to think about when am I gonna finish all of my charting? And so, you know, I finish up with the patient. And then as my my medical assistant's getting my other patients into the room, what I try to do is go in and document the highlight the things that I need to remember and then fill it in when I'm done. Um, I'm one of those people that my charts are closed at the end of the day. I don't know about the two of you, but I can't remember, you know, if somebody's uterus is antiverted or not the next day. I'm not gonna remember, you know, I'm not gonna remember was it their right shoulder or their left shoulder that was bothering them? Yeah. Um, so I write down the highlights of what I need to remember absolutely, and then I'll finish it up just so I don't forget those key aspects. Do you have anything that you want to add to that?

Jason Gleason 34:34

I do I do the same thing, you know, especially like uh the process I've gotten into doing, because you know, I I try to finish a chart before I go see the next patient. So it's locked, done, you know, move on. But sometimes that's not possible. But at a minimum, what I like to do just to stay on task, is as you said, you can't remember. Heck, I wouldn't even remember who had a uterus, you know. Yeah, forget everything else. But but it's tough from patient to patient. But what I do is I'll like go right to my desk, I'll order any consults that I need to add, you know, consultations, any labs that they're a return to clinic visit, because you know, when your patient leaves the exam room and goes up front, in most clinics, the people that are trying to schedule them for follow-up need that order from the provider, you know, for return to clinic. So I'll do that ahead of time, make sure those priority things are done, and then I can go back and fill in the uh the dots. But the biggest thing that I'd recommend for our listeners to do, because you don't know what kind of work environment you're going to be in. At the VA, we used to be segregated into different offices the providers were, and it was nice, but we were segregated, there wasn't a lot of connection. Now they put us in a big pit, just like the show, you know, on TV, The Pit. They put us in this big pit, which we love because we see everybody at once and there's five different teams, but it can be quite chaotic and distracting at times. So I'll tell you what, if if our listeners out there are going to do a lot of dictation through something like Dragon, which most most are some other software out there, limiting distractions, and you can use the the wand recorder, you know, and hold it up. But one of the things I love, and for our folks watching this on YouTube or other sources, this is your friend, the headset with the mic. It's uh now noise canceling. So again, it just all the distractions on the outside, even if you're in a big room, a pit, so to speak, get something like this to get rid of those distractions so you can stay focused. And then people also know stop coming up to me and tell me about every little thing that I don't need to know because it's really important that I'm documenting this correctly and ordering the right labs and medications and such. So really limit your your distractions down, which is not always easy, would you say?

Christopher Gleason 36:34

No, I actually would add one caveat to that. So I had a funny situation where I we dictate with Dragon and I had in Dragon, you can choose the mic that you want to use. Oh yeah, and I didn't realize that the mic that was chosen was the internal mic for the laptop, so it was picking up everybody's conversation. It became so frustrating for me because I could not figure out for the life of me why.

Jason Gleason 36:55

That makes your note interesting.

Christopher Gleason 36:57

It really does. So make sure to go in and choose that if you're using those power mics or you're using the headset, make sure to choose the right mic. Yeah.

Jason Gleason 37:04

Um, and yeah, and no naughty words should be in your dictation.

Vanessa Pomarico 37:08

So and make sure you read your note, because I can't tell you how many times I've read notes and it's picked up so many, and and I've gotten consult notes and it's it's had all this extraneous conversation, and the consult person just signed it and never read the note. So yeah. So we don't, we we have a very similar situation, although we call it ours the dormitory. Oh, I love it. Yeah, even better. There's five of us in in one room. Um although we do, we we are very cognizant of when somebody is dictating and we try to keep our voices down, especially if we're on the phone with a patient. So, you know, again, little tips of the trade, things that you'll kind of figure out, not all going to happen on the first day, but just things to kind of like raise your awareness. Um, one of the tips that one of the things I want to address in this uh episode, I know we kind of brought it up in an earlier episode, but um triaging the visit, you know, you get that patient that's scheduled for one particular problem and then they come in with 12.

Christopher Gleason 38:06

Yeah, absolutely.

Vanessa Pomarico 38:07

You know, so you know, we have to really then say in a very nice way that, you know, you were I'm I'm very sorry, you were only booked for this one particular problem. So let's address that today, and then I can have you come back and we can address, you know, something else at a later date. How do you guys handle that?

Jason Gleason 38:24

I love that. That's exactly what I do, and and very kindly, right? You don't want to set them up. I what I usually do to not minimize any of their concerns is I'll tell them something like, you know, all these concerns are great and I know that they're all important to you. And and to give you enough time for each of these to provide the best care, I really want to spend a lot of time on each of these. Can we break this appointment up over several? And then and then have them pick the first three that they want or whatever. But it it's tough, it's challenging.

Christopher Gleason 38:48

And that's what I do too. I mean, because we during our annual visits, oftentimes we'll have uh veterans that come in with, you know, kind of the laundry list of things that they want to touch base on. And I say, and I'll tell them, you know, choose your your top two or choose your top three that you want to get done today, and then we can make uh future appointments to to cover the rest of them.

Jason Gleason 39:06

Yeah.

Vanessa Pomarico 39:07

That's pretty good. And it's so important because, you know, our patients are so clued into, you know, internet searches and now AI searches. And of course, you know, they know more than we do sometimes. So um, they'll come in and they'll say, well, I already know what this is, but again, not to minimize anything, um, but just to say to them, you know, I I I wish I had more time to spend with you, but unfortunately, they've only booked for a certain amount of time. So let's address the most important things today. And your patients really can't get upset with you, you know, when you tell them you're gonna address these things and then make a point at the end of the visit to say, no, stop at the desk, schedule another appointment to see me in a week, and we'll go through a couple more of your concerns. And if you have any problems in the meantime, please reach out to me. Um that this way it kind of gives them that feeling like, okay, I guess they really do care and they're not gonna rush me out, you know, for no reason.

Jason Gleason 40:00

So you know, I have this one patient, I love this patient, it's such a wonderful gentleman, but you know, it takes him 20 minutes to walk from the the waiting room to the exam room because he he is truly close to 90 years old, a wonderful human being. And he gets in the exam room, and you know what I'm talking about. It's a visit that was 20 minutes that is now an hour. So I get through the entire visit with him. I think we're done. I think we're done because it we're already into this 60 minutes, and then he goes to his pocket and says, No, no, no, I haven't even started yet. And then he pulls out the list. It's like, oh boy, here we go. And it is as you you can probably relate to this, it's the same stuff that you keep doing over and over again at every visit. I believe. But I love the guy, and you just gotta make time for those patients. And if your clinic administration allows you to occasionally never abuse this because they'll pick up on it, but if they allow you for those more complex patients, at least 45 minutes an hour, you know, just to spend time with them. And if administration comes back to you and says, What is this hour-long appointment? No, that's not gonna happen. Use this word for patient safety, for patient safety and satisfaction, because those are big uh deliverables, right? And things that uh administration really pays attention to. So yeah.

Vanessa Pomarico 41:08

Hopefully that's so important, very helpful.

Christopher Gleason 41:10

I wanted to touch on touch base on one thing real quickly. You know back to you know, kind of the days where you where you feel like you're getting behind. When you when you are getting behind and you go to that next patient, it's so important to acknowledge their time. Yeah. You know, when you're coming into a room and you're 10, you're 15 minutes late for their appointment, the it's so important to say, I, you know, and for me, I say, I'm so sorry I'm late, you know, it's it's been a chaotic morning, what have you. But I think it's so important to acknowledge their time.

Vanessa Pomarico 41:37

Absolutely. And they appreciate that. And then I uh, you know, to to your point there, Christopher, you you don't want to if you're 10 minutes to late to their 15-minute appointment, you need to give them their full 15 minutes. You can't shortstrain shortchange them.

Christopher Gleason 41:52

Absolutely.

Vanessa Pomarico 41:53

Um, and make sure you kind of stick to that so that the patient doesn't feel like, great, I got five minutes of their time because they were running behind because somebody shelled showed up late. So and then sometimes what I'll do is if my patient shows up late and my other patient is there on time, I'll say to my medical assistant, you know what, put the one who's here on time and I'll work the other one in.

Jason Gleason 42:13

Yep, right. That's what we I do the same thing. Yep.

Vanessa Pomarico 42:15

And then when they're chronically late, which you know, we all have those patients that are chronically late. I I I just had to say this to somebody. When I tell you this one patient is late five to ten minutes every single time. And I finally said to her at the end of the visit last time, I said, I just want to make mention to you that every time you come in, you're five to ten minutes late. And that throws me behind for other patients. And I'm not sure, I'm not sure what the problem is, to be honest with you, because it's not like they um they're working out of state. So I think they're just one of those people that are, you know, they're always behind chronically late for everything. And I just say to them, it's really not fair to my patients who have to take time off from work or have to get a babysitter, or, you know, they have a sick family member, they've got to arrange for somebody to care for, whatever it is. It's not fair to them because now I'm infringing on their time. And so I try to make them aware that their behavior is affecting the other patients. And I only do this when the patient is not late one or two times, but we're talking every time.

Jason Gleason 43:17

Yeah. That's so that's very all right.

Vanessa Pomarico 43:21

So now we're leading into my favorite part is fact or fiction. Are you ready?

Jason Gleason 43:25

Fact or fiction, yes. Yes, fact or fiction. Bring it on, baby. All right, let's see.

Vanessa Pomarico 43:30

Five-minute huddle can prevent multiple downstream problems. Fact or fiction, Chris.

Christopher Gleason 43:35

Fact. Absolute fact.

Vanessa Pomarico 43:37

That's right. All right, Jason, previsit planning is only useful in concierge practices, fact or fiction.

Jason Gleason 43:43

Well, I am not fancy enough to work for a concierge practice, but I would say that's fiction.

Vanessa Pomarico 43:49

Absolutely. You're right. Right. Because concierge practices, you know, the patients pay a lot of money and they take a lot of your time. Yes, they do. All right, how about safety checks, things like allergies, anticipation? Coagulants, pregnancy status, those are all optional if you're running behind fact or fiction, either one of you.

Christopher Gleason 44:06

Fiction and absolutely not. Yes.

Vanessa Pomarico 44:08

That's right. Those are so important.

Jason Gleason 44:11

Fiction with a capital F. Yeah.

Vanessa Pomarico 44:13

You cannot shortchange your safety. Absolutely. All right. So again, I want to invite you all to please email your questions to nplaunchpad@f hea.com. Again, that's nplaunchpad@fhea.com. And we have a couple of on-air questions that I'd like to read. So, Christopher, what are the three things you'd put on your first day survival checklist?

Christopher Gleason 44:38

Get to know your supervisor, get to know your your chain of command is what I'll call it. Um, you know, know your security protocols and get to know really get to know your team, get to know your nurses, get to know, you know, who you're gonna be working with on that daily basis.

Vanessa Pomarico 44:54

That's right. Those are the people that are gonna support you when you need it the most.

Christopher Gleason 44:57

Absolutely.

Jason Gleason 44:58

Absolutely.

Vanessa Pomarico 44:59

All right, so Jason, let's say you start running behind and it's only 10 o'clock in the morning. What's your go-to move to get back on track?

Jason Gleason 45:07

The fake, sick, and go home. No, no, I'm not doing yeah, right? No, you'd want to though on some of those days, but you know what? It it's all about what we've been talking about, which is great. You know, prioritizing your documentation. You may not have time to finish that entire note, but get the important stuff in the consults, the meds, the return to clinic stuff, limit distractions, as I had mentioned. And then one thing that we didn't mention that I like to say is that when you are running behind, be genuine, be real, be super respectful to patients and apologize to them. And and they know your heart, especially if you build that connection with them and that relationship long term. But I also find that when you really get to know a patient well and they know you and your personality's gel well, you can also use some therapeutic humor, you know, to kind of lighten the atmosphere. So, but you gotta be careful with that because you don't want to make fun of somebody or make them irritable because you're the one that's late and it's their time, super respectful. But just today I was a little bit behind. So I go into a room and I say, I am so sorry. I know you're 35 years old and you've been waiting here for probably a hundred years, you've aged a hundred years waiting for me. I'm so sorry. And you look great for 135. I'm so sorry. I'm so sorry. Yeah, so you got to use it the right way, but sometimes therapeutic humor can help cut through the negativity. So it's tough.

Vanessa Pomarico 46:22

One of the things that I said to a patient once, um, I you've waited so long that what the problem you came in for is already gone, right? And then that really broke the ice. Yeah.

Jason Gleason 46:31

Yeah, it's therapeutic, it's therapeutic waiting, right? Therapeutic waiting.

Vanessa Pomarico 46:35

You waited so long you got better. That's right.

Jason Gleason 46:38

See, aren't you happy now? Yeah, my job here is done. Yes.

Vanessa Pomarico 46:43

So we appreciate all of our listeners and we want to share some special savings with you. If you visit FHEA.com and you use the code LAUNCHPAD20 for 20% off all of our CEs and memberships, right? Isn't that great? This is a thank you for helping to support our show. So go to the FHEA.com website and use the code LAUNCHPAD20, and you'll get 20% off a huge variety of our CE offerings as well as our different memberships. Again, as a thank you for supporting the show. All right, so our landing checklist, we have three take-home tips. These are going to be uh found right here on the screen. So create a first day checklist. Those are your logins, your workflows, and any of your escalation um contacts. Do your five-minute huddle before the clinic and pick one safety priority. And then run a five-minute pre-clinic huddle and pick one safety item to verify. Maybe it might be allergies, it might be your opioids, it might be your anticoagulants. So your homework for this week is to draft your first day checklist. Those are your things like your logins, your workflows, and your safety and print it out. Um, you can save it on your phone, but sometimes it's handy just to have a little hard copy of something. So that's your homework for this week is to create your first day checklist and uh see how you do with it. Hang on to that checklist. I have to tell you that I we used to have a little black book um when I was in my clinical. And I recently just threw mine out after almost 28 years. Wow. Still had it out. I felt like it was like my little safety belt. I was afraid to get rid of it. But I looked through it and I was like, you know, wow, what a newbie I was. Um but it was really, really helpful. Yeah.

Jason Gleason 48:26

And half these people are retired or dead by now. Right. Yeah.

Vanessa Pomarico 48:29

Right. Right.

Jason Gleason 48:31

Yeah. Exactly. Wow. Interesting.

Vanessa Pomarico 48:33

So we hope that you're enjoying our podcast series. We are having such a blast doing this for all of you. And then we hope you're all finding it helpful for your own practice. So we'd like you to help us out now by doing a couple of things. So drop us five stars if you think we deserve it. Hit follow and then tap subscribe. But more importantly, share this podcast with one of your NP colleagues or your friends and your family. And stay in touch with us by emailing us at nplaunchpad@fhea.com. That's a wrap on this episode of NP Launchpad. Thank you again for joining us and be sure to tune in for our next episode on charting that protects you. So until next time, take care.

Voiceover 49:24

And for more tools to power your NP career, visit FHEA.com.