Paper Medical Records

Specialties NP

Published

Hello!

I recently accepted my first position as an FNP at a university wellness center and they currently have paper charts and I have never worked in a facility that did not have an EHR. I will be the only provider so I won't have anyone to ask questions. Does anyone know of a good resource to learn how to utilize paper charts? In the next 1-2 years they will be transitioning to Epic and that can't come soon enough!

Thanks!

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Specializes in Cardiac, Home Health, Primary Care.

Paper charts typically just have tabs so I don't think there's any way to learn it besides messing with the charts in the clinic. You might ask for some sample forms you use so you become acquainted with your documentation. Make sure you have a good pharm resource since you don't have a EHR to check for interactions. Big ones I've run into is possibility of QT prolongation with macrolides (i.e. Z pack) with certain SSRI's (everybody has a happy pill now) as well as quinolones with certain meds.

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Specializes in Cardiac, Home Health, Primary Care.

And my clinics currently do a combination of paper and EHR as some of the old docs are resistant to the change and won't give up paper....

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Specializes in Birth center, LDRP, L&D, PP, nursing education.

I would recommend reviewing how to write a SOAP note. This is a quick article on the down and dirty basics of SOAP note charting.

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