EP 10: Charting That Protects You — Documentation Pitfalls

This episode of NP Launchpad dives into the essentials of clinical documentation and why it plays a critical role in both patient care and legal protection. Hosts Jason, Vanessa, and Christopher break down how to document clearly, thoroughly, and defensibly—especially when discussing risks, benefits, and patient decision-making. They also explore the impact of transparency in the era of open medical records, including how patients interpret and react to what’s written about them. Throughout the episode, listeners gain practical strategies to communicate effectively, protect their practice, and build trust while navigating complex patient interactions.

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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.

Jason Gleason 0:33

Welcome back, everyone, to all our listeners out there. And if you're watching us on YouTube or another resource out there, welcome to our podcast, NP Launchpad. We are so delighted to be with you once again. You know, we've been in to a few episodes now with all of you, and we are developing such a great connection with you, our audience out there, because you're our friends, you're our colleagues across the country and in fact around the world. And I just have to say, keep that interaction coming in, keep those questions coming in, that interaction. Give us feedback. We'd love to hear what's working about the podcast and what isn't. Because truly, this is your podcast. It's about you, not about us. We want to be helpful to all of you out there. So welcome again. This is Dr. Jake coming to you live uh through this podcast with my good friends, Christopher and Vanessa. Yeah, Christopher and Vanessa, how you been doing? Good. How you doing? No, how you doing? You just trigger my friends. Yeah. Christopher, what is new in your life?

Christopher Gleason 1:32

What is new in my life? Not much. Actually, I'm finishing up. I finished up my project for the doctor, my doctoral uh for my DNP, and I'm actually in the phase where I get all take all the data and write a chapter about it.

Jason Gleason 1:44

Nice, very nice.

Vanessa Pomarico 1:45

Nice. You're you know, the finish line is within sight here, Christopher.

Jason Gleason 1:50

Within sight. Now, Christopher, how long have you been a nurse practitioner for nine years? Nine years. No. Wow.

Christopher Gleason 2:00

No, ten years. It'll be ten years in June.

Jason Gleason 2:03

Excellent, excellent. Vanessa, how about you?

Vanessa Pomarico 2:06

May will be 28 years.

Jason Gleason 2:08

Isn't that incredible?

Vanessa Pomarico 2:09

Hard to believe. I know I was a child prodigy, right?

Jason Gleason 2:12

Oh my gosh, yeah. Absolutely, absolutely nuts. He's only 30. That's right. Well, I was gonna say 29, Christopher, but you know, 30. Yeah, you know, it's funny. Just the other day I was going through some old stuff, uh, a bin of books and things from my college days, and I came across the original Fitzgerald Health Education Associates review book that I got during the review course in 2001. And it was about this thin. And I thought, boy, now when we teach that course, the book is like four times the size, right? Because all the knowledge we have to have now. And I just thought, wow, where did the time go? Where did the time go?

Vanessa Pomarico 2:48

So I won't throw mine out. I have the same one, I won't throw it out because I have all my notes in it. And to me, that's a part of my history.

Jason Gleason 2:54

Yes, yes, indeed. Yeah, it's so cool. So, yeah. So we're just delighted to have our audience joining us once again because we don't see you as an audience, but friends and colleagues. We want to make that connection with you. This episode, we're gonna focus on the hot topic of charting the protects you. How do you chart smart? You don't have to write volumes and chapters in a Britannica encyclopedia sized record, but you do need to chart smart. We're gonna discuss charting the protect you. So let's dive right into our hot topic discussion. This is where the three of us discuss hot topics that are really important for you to understand and learn about, and hopefully share with us by emailing us. So we're gonna talk about how to chart SMART to protect yourself. So, Christopher, let's kick things off with you. What are some top charting tips that you would recommend for our listeners out there?

Christopher Gleason 3:45

Document, document, document. And what I mean by that is if you didn't document it didn't happen, the if for some reason, God forbid, you should end up in in court, your notes are gonna be there to save you. If in what I mean by that is when you have, if you have somebody that, you know, a litigation that's happened five years down the road, you have no idea what you did with that patient. But if you can go back to your chart and read through it and get a better understanding of what happened the day, um, the day in question and and what you did that day, that's gonna save you in the long run.

Jason Gleason 4:16

Well, and and with that point, you know, I I've done some expert witness work. And so when an attorney hires you, if any of you out there have that opportunity, it's a great opportunity. I learned a lot through the process. But what'll happen is they hire you, and this is what's gonna go on if you have a case against you, is the attorney for the patient will hire a medical expert or a nurse practitioner expert to review the record. And that expert knows what they're looking for, like let's say stroke, because that's one of my passions. I know what to look for in a chart for an appropriate stroke workup and treatment. So I'm looking for those key things. And that medical expert will look through your documentation. And if it if it's garbage or if it's too brief and there's not enough information there, that leaves it wide open. But if you document well as a medical expert, as an NP expert looking at the chart, I'm like, oh yeah, I mean, there's no case here. They've done everything correct, you know, according to the chart. That's a big deal to a law firm because they don't take cases easily. I I talked to one attorney and he said in their firm they only take like two to three percent of cases that are offered to them. They only accept like two to three percent because most of them do not have uh what they need to really think that they're gonna have a successful case. So I agree with you, Christopher. Make sure you document thoroughly. Lee, what do you think?

Vanessa Pomarico 5:28

Well, I will tell you that one of the I I agree with you completely about document, document, document. But one of the most important things a nursing professor who was a legal nurse consultant had said when I was in school was you document as though you have an attorney looking over your shoulder.

Christopher Gleason 5:44

Oh, totally. I love that. Absolutely. Definitely, definitely.

Vanessa Pomarico 5:48

So when I'm documenting, I make sure that as I'm doing it, that I create my problem list. And one of the things that I teach my students is that I say you always have to document something and make your note as clear as possible so the person coming behind you knows exactly what's going on. So instead of saying the patient has a red rash on their left arm, well, that's a lot of real estate to cover. So you need to be a lot, you know, you need to be a lot more clear and concise about it. And and again, you have to make sure that that person who's gonna come behind you, or even you picking up that that, you know, looking up that note or picking up that chart six months from now, you'll have a real good idea what the what it was looking like at that time.

Jason Gleason 6:30

Absolutely. Uh, you know, the other thing too, when you're documenting it, I think it's always so important, not that you just document, document it, but you actually do it is whenever you're talking about treatments with patients, whether it's medications, therapies, screening, you know, tests like a colonoscopy, I always go over the risks and the benefits and the risk if they don't do it. And make sure you document that well. And then the big thing that you want to do is wrap it up with patient verbalized understanding this, had the cognitive ability to understand it, and they agree to it, or they don't, and then list why they didn't. Document all that because I'll tell you what, if you don't close your documentation with something like that, that the patient understood, or the patient had the cognitive ability, or in some cases, even like if a patient has a history of a use disorder, you even want to put in there a patient appeared to be not under the influence of any drugs or alcohol. You know, make sure you close the loop on your documentation because if you don't, if something happens, a patient can come back and say, Well, I didn't understand what they meant. Right? I didn't, I didn't understand that. Make sure you make it rock solid and close it off by that, but go over the risks and benefits of any treatment you're gonna offer that document.

Christopher Gleason 7:35

And I'd add something to that too. You know, in your during your practice, you're gonna run across patients that are that are not gonna want to cooperate with your treatment plan, whatever it happens to be. I've had patients that have had significant hypertension that have tried to start them on medication, they've utterly refused to start the medication. What you want to make sure that you document is that you've gone through the risks of them not taking those medications and tell them, you know, the the risks can include death. You need you need to stress that to these people and uh to your patients, and you need to make sure that you document that as well.

Jason Gleason 8:05

You know, I I had one patient that sadly um had type two diabetes out of control, A1C is 14, and they haven't been on meds for years. And the reason why they were not on meds is because their faith that they followed told them that um that you should you don't need to be on medications, you don't need Western medicine, you can depend on nutraceuticals and those kind of those kind of things. It was very important to them. Their faith was. But in those cases where it's a huge safety issue, because this person's gonna have a heart attack or lose a foot or you know, have all the complications, in those cases, I I'm so respectful of them, but I also again make sure they know all the risks and benefits, but I also have them sign an AMA form and have that documented in the chart. And and I'm respectful even then. I say I respect your your faith or your religious background or your beliefs. It's not something I would recommend you do. You know, I still want you to do these things, but I respect that. And as long as you're well informed, you understand it fully, but I do need you to sign this form. And they usually do, they understand that. Right. It's tough. And those cases don't happen very often, but they will see them somewhere along the line. All right, moving on. Let's go down to our next odd topic. The Cures Act. 2016 is when the Cures Act first came out. It was it was first passed by Congress, and then it just had its final rule completed in 2026. The Cures Act. Basically, the gist of it is patients have access to all of their medical information documentation. So, and that's a big change. That's a big change. So I'll tell you what, I have run into some times when I'm documenting on a patient, and I have to remind myself that that patient is gonna see all of this if they want to. So you got to document very well, and we're not trashing our patients in our documentation. I'm not talking about that, but I'm just talking about sensitive things, like the way you document things about the patient. You don't want them to take it the wrong way. Or if a patient has a mental health illness of some kind or issue, you don't want to set them off with a trigger if they're reading your notes. You gotta be really careful with that. One of the things that I always do, I start my note with so-and-so is here in the clinic today, and they're a very pleasant, you know, male or female, whatever. And I usually start off with that just to kind of set the positive tone. But it's not always easy. It's not always easy. But patients do have access, full access to everything that you document, except for a few occasions. One of those occasions is if let's say you have a patient that is has a history of suicide uh ideation, or you know, they can potentially be homicidal, you know, triggers and that kind of thing. If there's any risk of harm to themselves or others, then the Cures Act makes way for that. Let's say a patient has a history of suicidal ideation, and you're gonna you did some tests and they come back with some test results where they have terminal cancer, for instance, and you know that that's gonna be a big trigger for them and you want to talk to them in person about it. There's those instances where, you know, you don't have to share that information all the time, but they're very few and far between. Have you run into that, Vanessa?

Vanessa Pomarico 11:01

Uh I I have. And um, you know, when the CARES Act first came out, it was really, and I'm sure you remember this, Jason. Um, it was kind of a nightmare because patients were suddenly calling up and saying, why did you put that I'm morbidly obese in there?

Jason Gleason 11:15

Oh, right.

Vanessa Pomarico 11:15

Yeah, yeah. You know, I I have to document it because that's part of our metrics as well. But when you have, you know, your weight, well, I don't want that in there. You know, why did you put that in there that I smoke? My significant other doesn't know that I smoke. And I then have to say to them, I have to document everything as I see it. And, you know, this is just what it is because when we get audited and the when I explain to the patients why so number one, it's for your health. Number two, if the you know, insurance companies audit us and they want to know why did I not acknowledge the fact that you have a BMI of 54, you know, and that I didn't address any of that, then that comes back on me as negligent.

Jason Gleason 11:56

Oh, yeah. So yeah.

Vanessa Pomarico 11:57

Um, it was really a nightmare. Um, we've changed a lot of our language, you know, um, like noncompliant. There is a diagnosis for non-compliance. And, you know, um patients don't like that word. And so, you know, but there's specific things. If they're non-compliant with their medical regime, you're gonna do it. You know, then that's something you have to document it. You know, um, you could like you said, Jason, you know, you may want to put in your note that, you know, you're seeing a very pleasant 74-year-old, you know, patient, but maybe they're not always so pleasant. Um again, you always want to start it on a positive note. Positive note. You know, two paths and a slap. You want to make sure that they're, you know, they're kind of happy with just about everything. Yeah.

Jason Gleason 12:41

And I'll tell you what, on those patients that are not very pleasant, they don't get it very pleasant. They're just pleasant. That saves my sanity. It's like at least I can mention something, right? Right. So, Christopher, what are your thoughts on this?

Christopher Gleason 12:54

So, one of the things I want to bring up with the CARES Act, and it's kind of like a point of contention with me, is I I understand and I and I um I agree with patients having access to their records absolutely. But when you have a patient that you've given, let's say they they've had a CT scan that's been performed and you're looking for, you know, some sort of carcinoma, then and and as a result, the CT, you know, comes back and they do identify some sort of some form of cancer. The patient has access to this or may have access to this long before you can actually tell them this or have that conversation with them, which can be very, very, I mean, traumatic for the patient because now they're reading in their chart that you know they they have this cancer, but you as a provider haven't had the chance to have that conversation with them.

Jason Gleason 13:38

Well, you know, and that's such a good topic. I'm glad you bring this up. You know, one of the things that I think is a horrible thing we're doing in healthcare these days is the apathy towards breaking bad news to patients. I think I see a trend happening with colleagues, even myself, because uh we're so strapped for time, is that you'll call a patient over the phone and tell them they have cancer, or you'll tell them some bad news over the phone. I think that's terrible. I think and sometimes you have to, like there's circumstances where you just can't have them come in. They can't do that. They might be out of state, something urgent. But if you can at all, for our listeners out there, here's a great tip for you and piece of advice. Always break bad news in person. And the other thing you want to do when you break bad news is make sure you have a plan in place. Joe, I'm so sorry today to tell you you have cancer. But you know what, Joe? We're gonna give everything we can to this fight and we're in it with you. And here's your next step, here's your appointment with the oncologist. Already make all that stuff, get it done before you even go in and see the patient. So they have some kind of plan for follow-up. But it's tough. Yeah. So in and them reading it in their chart, again, the Cures Act allows that in some cases, but you can block some of that information. But you have to really justify it. Like there has to be a mental health issue, but they truly are going to harm themselves. It's not just you can't block it because it's bad news, but what would their response be?

Vanessa Pomarico 14:55

Well, but you can also, uh as far I know in our system, we're able to not release it immediately.

Jason Gleason 15:01

Yeah, yeah. Yeah. Wait.

Vanessa Pomarico 15:03

Um, and so I tend to use that if I really suspect somebody has a mask. But one of the things you can do, because you know, if you call the patient on the phone and say, you know, Joe, can you come in? I want to go over the results of your scan. You're gonna know something's bad. Oh, yeah. Right, absolutely. And and I'm gonna tell a true story. When I was very early in my career, I had a young woman that was, I I suspected had lymphoma. And sure enough, she did. This was way before we were on electronic health records. And I called her and said, You came into the office, you know, I really need to talk to you about, you know, your results. And she said, No, you have to tell me over the phone. And I said, Well, why don't you just come in and bring your husband with you? They got into an accident on the way to my office because they were so stressed. Yes. And so, so that's that is really difficult. So if I really suspect it, what I do is I say to the patient, um, I'm setting you up for the exam and we're gonna do it on such and such a date. I want you to come back in the office on such and such a date. Yeah, both this way, good, bad, or indifferent. They have an appointment to see me. I delay the release of the results. And then this way I can go in and I don't sugarcoat it. I walk in the door and go, good news, you know, or I walk in the door and go, okay, I don't have such great news for you to, you know, I do away with all the niceties. They're not listening to you anyway. They just want to know yes or no, am I gonna die or am I gonna live? So you know, try to hand it to them as as quickly as you can. But but again, having that appointment set up ahead of time really works well.

Jason Gleason 16:34

It does, it does, you know. Yeah, and one of the things with documentation, when going back to that is our previous hot topic, um, that really is helpful, I find, is because you there's some things that are really hard to document and you know the patient's gonna read it. So with AI, like at our work, we have AI on our desktops and it's approved for the VA and it's medical-based and it's secure, but I never enter, you never, ever, ever want to enter any uh personal information from the patient into AI at all. Never do that. But let's say I I've written a few paragraphs in my note on documenting something very sensitive. I'll copy that, I'll paste it into uh the AI, and then I'll ask AI, how can I make this sound appropriate where it may not be a trigger for the patient? And it does it. It'll give you some great ideas. And you always have to double check it because AI can be wrong, right? Don't depend on 100% and never again add any personal identifying information. But I I use it and it's a great tool. And often it'll be like, oh, that's a good way to think about that and to chart that. So use your tools.

Christopher Gleason 17:33

Another way to use AI too is or that I've used in the past is actually taking um results from an X ray of results from any sort of imaging study. Again, don't don't include any patient identifiers in it. Take it, cut and copy, and put it into the AI and ask it, you know, how can I make this more patient friendly? How can I help our my patient understand this? And it actually will reword it in such a way that your patient will will be able to better understand the results of their imaging study.

Jason Gleason 18:00

That's great.

Christopher Gleason 18:01

Yeah.

Vanessa Pomarico 18:01

Great idea.

Jason Gleason 18:03

Moving on over to our next hot topic. Let's talk about when copy forward can be helpful or harmful. And what we're talking about here is when can you in your EHR, let's say you have a template and you have a patient note, and part of that note is never going to change or rarely change, like social history, for example, right? When is it appropriate to copy parts of the chart, the progress note from when you saw them before, and carry that forward into the new note? And what kind of things could set you up to make that really harmful to the patient and you might miss that? So let's talk about that. Vanessa, do you ever do this? And how do you what safety things do you put in place so you don't mess up when you do copy forward?

Vanessa Pomarico 18:40

So I'm old school, I do not copy forward.

Jason Gleason 18:43

Wow. Yeah.

Vanessa Pomarico 18:44

I I just, you know what? We I have seen too many errors that were done with copy forward. Um, and our legal department really, really cracks down on people for doing copy forward. Every one of my templates is a brand new, fresh template. What I will do is like let's say I have a follow-up on a motor vehicle accident.

Christopher Gleason 19:06

Yeah.

Vanessa Pomarico 19:07

What I will do is say patient is here for follow-up on a motor vehicle accident that occurred on such and such a date. For further details on this, please refer to my note dated so that this way if it gets called into court, they just refer back to my original note and I don't have to recreate the wheel.

Jason Gleason 19:23

I love that idea.

Christopher Gleason 19:24

That's a that's a great idea. Yeah.

Vanessa Pomarico 19:26

Yeah.

Jason Gleason 19:26

Really good. Christopher, how about you? What are your thoughts on this?

Christopher Gleason 19:29

Um, I actually agree with Vanessa. I don't copy forward either. Um, my I use templates to to save time, but my templates are, you know, just that. They're a template. There's no information in them. And the I just don't want to risk if I copy forward and there's misinformation in there. And like, you know, V said, if it gets called into court, then they can review these records and be like, well, you said this, but it actually didn't happen. This happened, it happened on a previous date or whatever.

Jason Gleason 19:54

And see, I am the exception here. I'm the exception. I do copy forward, but I do it very carefully. Like you mentioned, you've got to be super careful with this and don't get lazy with it because that's when things are gonna happen. They're gonna be horrible for you as a provider. But but the safety nets I put in place are this. I'll copy forward the note. And that chief complaint is always gonna be new, right? So that section's always brand new. But copy forward for me, I copy forward the review of systems and the physical exam. You've got to go back, you've got to double check that every time because that could change. Likely your entire review of systems is not gonna change from visit to visit, right? But it does change in some ways. So you got to go back there and you got to make those adjustments and then physical exam, same thing, right? It it's not likely gonna be all new for the patient, but again, you've got to go back there and change that. Because if not, like if something happens and your documentation has the same physical exam as the last 10 years, no changes at all. They're gonna pick up on something, you know. But so I do I do that, and it it saves me time. I I that's what I appreciate about it. But you've got to be super, super careful out there if you're doing that, just double check and and most importantly, check with your organization because some organizations ban it, they don't want it done at all. So make sure who your administrators are and and uh and what their thoughts are on it, if there's a policy on it, and they should have safeguards written into that policy of things that you should do to make sure it isn't harmful, but it's actually helpful too.

Vanessa Pomarico 21:16

So and most important, don't copy forward someone else's note. Oh, absolutely to save yourself time. Right? Yeah, and as new providers, that's really what you need to think about. You you know, there's some people that will say it's okay to do this, but in a court of law, they're gonna say, so it's interesting that, you know, your you know, review of systems or your um your you know, um exam is exactly the same wording that was in Dr. So and so's note dated, you know, July 1989. Um so you have to make sure as a new provider that you are creating your own words and your own descriptions.

Jason Gleason 21:57

Absolutely. Yeah. And you know, even like test. Results often what I'll do, like if you have a very long radiologist report that you're going to refer to, just for accuracy and time's sake, I'll copy like their their findings and I'll put that in my note, you know. But then I'll list there this is from the radiologist report as a source, right? Underneath that, you want to list that just to make sure if somebody's reviewing the chart, they know where you're getting that information from. But I'll do that some of the time. But again, caution, caution, caution is the key and just to really double check things and make sure you know what your organization is doing. So how about templates? Christopher, what are your thoughts on templates?

Christopher Gleason 22:33

I actually I actually use templates and I I like them. Um, but it is very important if you're using a template to in my case, I have a template for my uh ROS, my review systems, and for my my physical exam. And that is because each time that I I see a patient, I make sure that I both do the same ROS with them and I make sure that the things that I detail in my physical exam are the same things that I'm I'm examining in the room. So it and if something changes, if their ROS changes, then I go I'll change it. If if for some reason, you know, in my template it says like lung stones are clear, kind of like is the standard. If their lung stones aren't clear, I'll say, you know, lung sounds were decreased, uh, bilateral crackles noted, things like that. So I'll make sure the chain gets brought through. But it's so important to make sure you change it because if you don't, that template's gonna look the same over and over and over again. Oh yeah. And it's gonna look like the the patient's a you know a stellar, stellar patient. And in in actuality, they may not be.

Jason Gleason 23:27

So it might be a train wreck. Yeah. That kind of stuff. Vanessa, do you love templates? Are they your friend?

Vanessa Pomarico 23:33

You know, Christopher and I are totally on the same wavelength with us. I could not get through my day without my dot phrases and my templates. But like Christopher, you know, it's really to help transit, you know, smooth things out and help me to um really spend more face-to-face contact with the patient as opposed to just typing away. Um, but again, you know, don't make sure that you're changing them because, like you said, if you document that the lung sounds were clear and the patient has a whopping pneumonia, that's a liability.

Jason Gleason 24:00

Oh, yeah.

Vanessa Pomarico 24:00

Yeah. Yeah.

Jason Gleason 24:02

Never a good thing. And to to kind of wrap up this hot topic, never sign a note that you would not defend in court. And that's not always easy. Because I'll tell you what, when I run into this, this kind of question or issue is when you have a very complex patient and the note in the chart you know is going to be 10 pages long because you're doing all this documentation. And it's like five o'clock at night, six o'clock at night, you're still so far behind. Take the time, invest it just to double check that record because again, once it's in there, it's in there forever. Garbage in and it's in the chart forever and ever and ever. So never sign a note, you would not defend in court. Let's go on to our next hot topic: how documentation protects you and your patients. Let's talk about this a little bit. And we've already added a lot to this in our discussion previously. But I I see documentation as your shield and it dock and you want to document clinical reasoning, communication, safety planning. I think it's important to do that. Your reasoning, your rationale. Well, why did I choose this treatment over another? And did I review the considerations with the patient? It's okay to chart all that. And I find it's it's quite helpful to do that, not only to protect you legally, but when you see the patient in the future, you're thinking, oh, that's what I was thinking around developing this differential diagnosis list, or this is why we went in this direction instead of that one. If you chart those discussions there, it's going to save you in the long run because you you can't remember three months down the road what you discuss with the patient. So that's where I find that helpful. Christopher, what what tips on charting do you have?

Christopher Gleason 25:28

One of the things that I would definitely tell our listeners is um return precautions. So if you're if you have somebody that that you're seeing for hypertension, let's say, and you've started them on a medication, make make sure that you're documenting that you've you've instructed them to monitor themselves while on medication. Something that I'll often do is if I'm starting somebody on lysinoprol 20 milligrams, I'll say, you know, veteran was instructed to take the medication, take their blood pressure 30 to 40 minutes later, uh, document that, and they'll follow up with the RN to discuss results. Make sure that they know that that plan is in place and what the um return is going to be.

Jason Gleason 26:04

Excellent. Vanessa, what would you add to that?

Vanessa Pomarico 26:07

So these are all great points. You pretty much took everything I was thinking too. But one of the other things that I would say that if you're not really sure about something, you know, like let's say you see a patient and you don't think they have a sinus infection, but you know, maybe they might have something brewing, um, or, you know, let's say something more serious like chest pain, and you're ruling out all the more serious things um first, make sure that you take extra time to document that, that you put in your um, your differential diagnoses and any red flags, because in this way, the differential diagnoses, if you put in there in the note, and I always find it helpful when the ED does this and it says differential diagnoses include, you know, I don't think the patient has such and such, and they give the rationale. It's a little bit more documentation than you normally would do. But if there's kind of a tenuous case, then it's worth it to spend that extra time putting those explanations in place really to cover yourself.

Jason Gleason 27:07

Yeah. Absolutely. If you think about it, that you're gonna wake up at 3 a.m. in the morning worried about how you documented, you better double check stuff. You learn how to do that, you know. Yeah. So you have that tension around your documentation, spend the time. Spend the time. The other thing as we wrap up our discussion on this hot topic is uh dragon and other voice dictation systems out there. I always find it humorous when I go back and look at my notes because it says something I completely didn't mean. Like if, for example, we have a wonderful, wonderful oncologist in our community, amazing, and a good friend of mine. His name is Dr. Gooter, but in the chart, it comes out as Dr. Cooter. And I always thought, wouldn't it be cool marketing if you were if you were a gynecologist, but not an oncologist? Yeah. So look out for Dr. Gooters being Dr. Cooter's in your record. You don't want that. So yeah. Have you ever seen anything funny like that, Vanessa, when you've looked at charts?

Vanessa Pomarico 28:00

Oh, yes. And some of them, again, they if you don't read your note if you're using one of the dictation systems and you go back, you can't go back and change it once you've reached the note. No, you have to make sure you take the time to read it over. I actually sent a letter back to one of the orthopedics to say, I have no idea what all of this means in here, but could you just tell me what happened with the patient? And he was just getting used to using the dictation, and he said, Oh, nice, I'm so embarrassed. How do I take this out of here? I'm like, how am I supposed to know? Call your administrator. I don't know what system you're on. Like, he's like figure it out. But you're supposed to read these things before you sign off on. That's right. That's right.

Christopher Gleason 28:42

Yeah, it's very important to do that. Actually, I was I had gone back and read through a note. One one of the things that's important too is to make sure that your mic is because that will it will pick up throughout my conversations. And I was re reviewing a patient's chart and there was a pizza order in there.

Jason Gleason 28:55

Oh, a pizza order. Very nice, very nice. Yeah, nice. So good tips for all of our listeners out there, right? So now I'd like to share with you some resources, and these are going to be found in the show notes. So if you want more information on these hot topics, here are some great resources for you. And our team is gonna try for those of you watching this on YouTube or another source to actually put on the screen right now. But these are some great resources. If you go to the show notes, there's actually links in there that you can click on. It'll take you right to the resource so you don't have to do anything or write anything down right now. So, number one, Office of the National Coordinator for Health Information Technology, ONC, has all that information about Cures Act information. You remember how we talked about those times where you have blocking exceptions? It goes into that. So the website for that is listed here on the screen for you. It is also in the show notes. Another great resource is the HHS O C R Health Insurance Portability and Accountability Act Information, HIPAA. We all know what that is. But here's a resource for you there to look through, and you can search through that for the key things you need. That said, let's go into our favorite part of the program, fact or fiction. Who's gonna be the boss out of all this, right? Out of these questions. So, Vanessa, let's start with you with fact or fiction. Patients can often see your notes quickly due to the open notes, yours act rule.

Vanessa Pomarico 30:15

Sadly, it's a fact.

Jason Gleason 30:18

It's a fact, absolutely. And so I don't like it, but it's a fact. Yeah, it is a fact, it is a fact. Christopher, you're up to plate here. Vague language like patient is fine, is protective documentation. Absolutely not. Yeah, that's garbage, right? Fiction. Excellent. And then copy paste. This is a toss-up between the two of you. Copy paste can introduce errors that follow a patient for the rest of their life.

Vanessa Pomarico 30:42

Facts.

Jason Gleason 30:44

Absolutely. So be smart, chart smart, right? So let's take a look at our mail drop. And I love this part because it's where we get to interact with you, our listeners, our friends, our colleagues out there. You've submitted some great questions. And if you have a question or even a comment, you want to tell us some news, share it with us. nplaunchpad at fair email us any information you'd like to share with us, except for patient information. No patient identifying information. Never send that to us. We don't want that. So let's take a look at your questions. What's your biggest documentation headache? Boy, there's a lot of those, right? Open notes, copy forward or documenting sensitive topics, Vanessa.

Vanessa Pomarico 31:27

Well, you know, my answer is going to be your copy forward because I don't mind the open notes. And I don't mind documenting sensitive topics because, again, I've been doing it long enough. But for those of you that again, you're brand new at this, don't be afraid to reach out and ask somebody, how do I document a sensitive topic? How do I finish this note? Because again, with the Cures Act, our patients are going to have access to this. So if you have any difficulty with it, don't be afraid to ask somebody to help you with that. So I would say for me, copy forward is a problem.

Jason Gleason 32:00

Excellent. Christopher, anything to add to that? No, I think we pretty much covered it. I think we've covered a lot of stuff here, which brings us up to our next question, which we've answered in many ways. But Christopher, out of all the things we discussed about templates, what is the number one thing you love about them the most? And what is one thing you hate about them?

Christopher Gleason 32:17

Um one of the things I love about them is their time-saving feature. It really does save me a lot of time. Um, one of the things that they not really hate about it, it's just to be uh cumbersome, is just making sure to go back through your templates and making sure that you make those changes that are needed um with your uh patient assessments.

Jason Gleason 32:35

Yeah. You know, one cool thing that I forgot to mention about templates, which I love, and every EHR is different. But at the VA REHR, I think it's an amazing feature when you're building your templates, and as a new NP in a practice, spend some time, maybe an hour extra night staying after work to create these templates, because in the long run, it's gonna save you a ton of time, right? But one of the things I love when you're building your template, and every EHR is different. So check with your IT department out there, they'd be the ultimate resource to go to. This information is usually given to you during your orientation period. So you have that extra time built into your schedule to do things like this. But in REHR, like if in my template, if I wanted to drag over the medication list, it will. The vital signs, it will. It'll plug all that in there. And so there's a lot of those cool features. So look for those too, because you don't have to create your own templates. Plus, ask your colleagues, your buddies, your friends out there, hey, do you got any great templates? Can you email me the format in a Word document and then copy that, put it into your template, you're good to go.

Vanessa Pomarico 33:32

I just wanted to add something. You all those great things you just said about um, you know, copying forward, you know, and sharing templates. But within the electronic health system, they generally will allow you to share your templates with other people within the system if you um check off, you know, that you can share with anybody. And I do that with all of my templates. They're they're good for anybody who is on Epic within our healthcare system. Um, they have access to the templates. So just ask if anybody has templates that are already ready for you to just be able to um uh acclimate into your own system. That's awesome.

Jason Gleason 34:05

Yeah. So so a lot of networks out there actually have files that you can just click on where everybody dumps their templates into, and there it is, right? Or you can share, click share on different different software. So excellent. Yeah. Well, our our listeners, our friends and colleagues out there are gonna love this. How many of you love discounts and to save money, right? This is a big deal. So this is something new we're offering through our podcast because we appreciate all of you listeners out there. And again, we're your friends and colleagues. We want you to save money because we do, we want to save money too. So if you go to our website at FHEA.com and you want to sign up for a course, a class, go to the bookstore, any of that, if you use the discount code, now pay attention to this. Write this down and remember it or replay it or look for it in the show notes. If you use this code when you're purchasing anything through FHEA.com, you get a discount. How much is the discount? 20%. How cool is 20%? Christopher, is that cool? Yes, it is very cool. Vanessa, would you agree? I would take it. Absolutely. I would take it. I wish we could do this. I'm gonna be going to the website and using that. So launchpad 20 is your code. Launchpad 20. Launchpad and 20. Launchpad 20. We give you 20% off all CE and membership fees through the website. And that discount code is given to you in appreciation. We want to thank you for supporting our show and for sharing it with all your friends. Well, let's wrap things up. This is your landing checklist, free take-home topics for you to follow. Add a patient-friendly summary line to your documentation, create a dot phrase, not many, just one. Make it easy for yourself. Create a dot phrase for safety counseling or another topic of your choosing. Chart like you'll read it in court, and your patient will read it tonight because they can and they will most of the time. So those are your three key elements to consider. And then your homework for this week is pick one documentation habit to stop. Copy forward loading, vague review of systems. Look at your documentation like you're you're maybe a professor, somebody that's gonna critique your own documentation. Find something in there that you can improve on, because all of us can improve on something, right? So pick one documentation habit to stop doing to improve your documentation. And lastly, as I close up here, I'm gonna ask you for a favor because we're friends and colleagues out there. Please drop five stars, five stars for our podcast when you're rating us. If it if we're not five star worthy, let us know. We want to fix that because we truly wanted this to be a five-star experience for all of you. Also, hit follow. Follow our program, tap subscribe because subscribers are going to get some extra additional information. And then most importantly, and I truly mean this genuinely from the heart, please share this podcast with your friends, your colleagues, maybe registered nurses out there that are going to NP school right now. Anybody that is interested in being a friend of or that is an NP themselves, please share this podcast. You know, it's not about clicks for us. Like we don't look at a number and say, oh wow, 100 people join the podcast today. I could care less. But what I do care about is you sharing our podcast because what that means is that we're building a bigger community, that we're helping more people. And you know what? Together we're stronger, right? As NPs in a community like this. So share this, share it with your friends. Maybe put it on a bulletin board at work. Hey, here's this great podcast. Share it with your friends because the more people that interact with us, the better we're all gonna be. So thank you so much for tuning in, Vanessa and Chris. What a great show! Thanks for joining me uh during this episode. We'll see you all next time. Thank you. Take care.

Voiceover 37:46

Bye now. You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.