During this rotation part of my position as a PA-S at the clinic required me to complete progress notes for all the patients that I saw. After about the first week of the rotation I was instructed to see patients on my own. I would greet the patient and then subsequently follow the clinical approach my preceptor taught. Then my preceptor would come see the patient with me and after his history and physical we would formulate an assessment and plan.
Progress notes were written and stored on a computer software, and my preceptor structured the software so that there were many templates that would be used for filling out the progress note. For example, if the patient presented with and was diagnosed with GERD, I would type in “esophageal reflux” in the template search bar and then click the arrow to populate the note. That template would automatically fill out the chief complaint, history of present illness (HPI), physical exam, assessment, and treatment. This was useful but I also thought it was sometimes too generic or not detailed enough for the patient’s specific presentation. Typically I would use the template and then go back and edit the HPI so that it included details the patient said during the interview.
Oftentimes the treatment would be appropriate for the patient, but sometimes the doctor would change it to tailor it to the patient’s particular needs. This was good, but I did not really learn how to know what to change the medication to or how to adjust the medication dosage. This is something I still need to practice.
This clinic has only been in the area for about two years and the number of patients seen each day is not overwhelming, which is great for my pace at this time in my clinical experience. On the days where I would see patient after patient, I would not be able to complete the progress note until after the rush of patients. By that time I would maybe have three or four patient encounters to complete. Usually during the patient visit I wouldn’t type the HPI while talking to the patient so during the lull times I finished up notes.
I found it to be a little repetitive and a lot of work, though I recognized the importance of a good note. Sometimes when I read older progress notes from previous patient encounters it would be difficult for me to get the full picture when the HPI basically only consisted of the template’s description. The whole point of the note is to communicate to other health care providers a comprehensive picture of the patient’s condition. If many details are too vague or left out, it makes it very difficult for the provider to fully understand the reasoning behind previous visits assessments and plans, and also it is annoying for the patient to have to explain themselves visit after visit.
I remember one day after work I went home and I told a friend that I realized being a PA is a lot of work. Of course I knew this going in, but oftentimes in class I only thought about making the diagnosis and coming up with the management plan that the documentation portion of a PA’s duties went over my head. In my first rotation I never wrote the notes, so when I got to primary care, my tasks were such a contrast to emergency medicine. I would not say that I really enjoy writing notes but I know how important it is to a patient’s medical care, and I would not skimp out on work just because I felt like it was a lot to do.