Some providers are lucky enough to use electronic health records (EHR) that have all the bells and whistles to show you what you need to include and where. No clunky slowdowns or inefficiencies. Other electronic records are…less robust.
Regardless of the EHR system your company uses, it’s important to make sure you have your own efficient, consistent, and clear system of documentation. Charting in this manner will not only save you time on subsequent visits with patients, but it will also make you a well-liked provider by other clinicians who read your chart for mutual patients.
I never felt completely prepared to write quality, efficient notes while in school. I learned the fear surrounding liability and about the importance of not documenting “too much.” Luckily, over time, I learned to write efficiently and clearly for my understanding and sanity (and other providers’ understanding and sanity who needed to review my notes).
Charting nuances
There’s already a lot of general advice out there about how to chart more effectively, and there are aspects to emphasize that differ by specialty. For example, if you’re a psychiatric nurse practitioner, the risk assessment section is critical to have in a note while for primary care, this is not necessarily the case.
There are nuances of what is stressed in terms of documentation by different specialists. What is important to include for all providers to streamline notes is a standard introduction to the note and a clear plan of action at the end that ‘builds’ from previous notes.
HPI One-Liners
I learned about HPI one liners from an experienced provider when I was beginning my career as an NP, and I’m so grateful I learned this tip. I’d never heard of an HPI one liner in school. History of Presenting Illness (HPI) One Liners are an informative sentence at the beginning of your note that includes all the pertinent information. It’s like a delicious amuse-bouche before you continue with your meal (or, in this case, the rest of your note).
HPI one liners are important because they tell a busy provider all the important information they need to know right upfront. No subtleties here. A clinician can get so much information from this single sentence.
They’re easy to write, too, because they follow a set template and help you stay organized because they follow a simple structure. HPI one liner sentences are helpful for you in follow up visits with patients. And these one liners also help other providers with whom you share a mutual patient or for providers taking over your patient.
Sidenote: there’s nothing more frustrating than taking over the caseload of a provider whose been with a patient for years, and the provider’s notes are vague and disorganized. Sloppy practices! Starting your career off with good habits like clear, efficient charting is a great way to begin.
But back to HPI one liners.
How to write an HPI One Liner
I love templates and following an organized system to stay on top of things.
The general format of an HPI one liner is as follows:
Patient (or insert name) is a ____yo (male/female etc) with history of ________(past medical history), _______ (past psych hx), _______(substance use disorder history), ______(other details relevant to your specialty), who presents for _________ (initial evaluation, med management follow up, etc.).
Here’s a more concrete example:
Patient is a 45 yo Caucasian male with a history of COPD, past psychiatric history of Major Depressive Disorder, and one past suicide attempt via self-injury who presents for initial psychiatric evaluation.
Now notice that this type of HPI one liner is more tailored for a mental health provider. If you’re a family nurse practitioner and see patients for management of their diabetes, you likely wouldn’t get too involved with talking about their psych history or hospitalizations or suicide attempts because you’re not treating that.
The beauty of HPIs, though, is that they capture a ton of important information in a short snippet.
‘Plan’ section of the note
Not to say that the beginning and the end of things are the most important—because often the middle is the best part—but in notes, the end is an important part to get right in terms of clarity. The Plan section includes the treatment plan of the next steps.
The assessment section is sometimes lumped in with the plan and might look something like this:
“Diagnostically, current presentation is consistent with Bipolar 2 disorder…differentials are substance-induced mood disorder, Persistent Depressive Disorder, etc.).
Something that’s often left out of Plan sections of notes is what was previously done, the previous plan. Unless you are a savant with memory and can recall most all details of all the patients you see, it’s a great idea to keep a running sort of ‘tab’ of your treatment plan history with patients. You want to date each time you make a medication adjustment or plan and then include it in subsequent notes.
Doing things like providing the timeline of when you make a medication change and why is SUPER helpful for writing discharge summaries or refreshing yourself on patients you haven’t seen in a long time.
Benefits of an organized ‘Plan’ section
If you treat a patient several times and make multiple adjustments over time, it’s great to know what you did so you know how to proceed going forward. Or, if another provider takes over, they can review your chronological plan section concisely without having to read all your notes.
An example of this could be:
Plan—
9/20: Auditory hallucinations have dissipated. Patient is tolerating medication regimen well, continue risperidone 0.5mg in morning and 1mg at bedtime. 30-day supply given, 1 refill. Follow up in 6 weeks, sooner if needed.
9/6: Patient tolerating risperidone well. AIMS was assessed with score of 0. Continue risperidone 1mg at bedtime and start 0.5mg in the morning for auditory hallucinations persisting through the day. Obtain repeat EKG to assess for QTc prolongation.
8/23: Lab work reviewed and found to be unremarkable. EKG showed no evidence of QTc prolongation, QTc 416ms. Start risperidone 1mg at bedtime for auditory hallucinations. Will increase if hallucinations persist.
8/16: Obtain baseline bloodwork including CBC, CMP, TSH, lipid panel, and EKG. Consider starting low dose risperidone as patient previously tolerated.
Notice that the most recent plan recommendation (on 9/20) is listed at the top, and the first adjustment is at the bottom (8/16). Keeping a running tab of the medication adjustments allows you to stay organized and clear with yourself and others who access your notes.
By consistently using the HPI one liner and having an organized chronological Plan section outlined in every note, you will clearly convey important information that your future self will thank you for. You will also likely very quickly become a well-liked provider to anyone who needs to access your notes.
