First psych NP job- struggling with documentation

Specialties NP

Published

So I've been on the job now for 2 months. This is my first real NP job since graduating last December. I was supposed to start another position in June but that did not work out. In any event, I work at a community mental health center. Overall, I love the job. It is a super busy clinic. We service a lot of people in the county. My issue is I work through my lunch break often and I'm at work an hour sometimes 2 after the clinic is closed! finishing up documentation. I see a lot of new patients. I get an hour for new patients. Med management is 20 mins. I find the EMR, burdensome, so that's one reason. The form is not exactly user friendly IMO. Of course I've gotten better with using it since I first started.

So maybe this is a silly thing that I carried over from my days of being a floor RN that just will not work as a working NP. Whenever I did my assessment as an RN , I always wrote my notes on paper then typed them up. I never liked talking to the patient and typing at the same time. I see, that will not work for me as a working NP. Way too many patients to see.

When I look at the initial psych eval and med management notes for the patients I have inherited, they tend to be a lot more concise than mine. Sometimes in a good way and sometimes not.

Maybe its newbie jitters. I took over the patient load of a doc that recently left. I'm actually shocked at the brevity of her documentation. I'm just afraid if I don't have it all down, that I will miss something. Which of course leads me to be at work for an hour extra. Help!

Any pointers for improving to documentation to make sure you get all you need while being concise?

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