What Software do you use to document?

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Hello, I have recently accepted a part-time position completing face to face encounters for a small Hospice; mostly rural visits. It isn't too many visits each month just a nice supplement to my income here and there- also I have worked for them as an RN and enjoy the patient population. They have asked me if I can use the software that RN and LPNs use for them, it is called Barnstorm. I initially agreed as I am familiar with the software and can bang out a note pretty quickly, but am now having second thoughts. I thought it would be a good idea using the same software as it would be more connected to the rest of the employees and they could access my notes- but the software is not made for a provider. Though I could theoretically free hand most things which I was doing as an RN anyway, the software is set up by organ system and focuses on physical examination with some ROS aspects incorporated, I like more of a SOAP format. My other option would be to just write a long-hand note on paper or in word. What are others with a similar position doing?

Thanks!

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Hi, You might want to look into using practice fusion. It is free and cloud based and from what I remember it was in SOAP format. I haven't used it for over a year now but it seems like a good option to consider for you if it is still similar to what I remember. Good Luck.

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my current practice uses practice fusion for patient charting. it is cloud based, free and in SOAP note format - so you can also work on it at home if need be. they have pre made templates but you also have the liberty to create your own templates as well to format it to what you want, we use this to to e-prescribe.

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Specializes in Internal Medicine.

My practice uses eClinicalWorks. It's expensive but it does charting and billing all together and ensures your notes are incredibly thorough.

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For the 3 jobs I am gonna be working as a new NP, I will be using Practice Fusion (community clinic), eClinicalWorks (IM), and the old-fashioned paper charting (Wt Loss Clinic).

Practice Fusion is in SOAP note format. It is free, user-friendly, and like the previous posters said, you can make/edit/delete your own template. I have my own templates that I love to use (because I personally made them).

eClinical is a little bit difficult for me to use. I think it's because I have never used it until this IM job. I find myself getting lost many times. But like all EHR, I am pretty sure I will be able to overcome that learning curve. You can also make your own templates. Like Riburn said, you can use the software for billing, escripts, etc., so it is more convenient for the clinic. It is not free though and heard it is expensive.

The old-fashioned paper charting is only good if you work in a fast-paced setting. At the weight-loss clinic, it's mostly refill visits (controlled substances), unless there's a new patient. The drugs are manually counted at the end of the day so I can see how paper charting would be better for this clinic.

My recommendation for your type of setting is Practice Fusion. Good luck!

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My practice uses eClinicalWorks. It's expensive but it does charting and billing all together and ensures your notes are incredibly thorough.

Riburn,

eClinicalWorks is a little bit difficult to use. How many days of practice (using the software) do you think I should ask my employer? I am high-tech and a computer savvy but this software seems to be a challenge for me. I got lost in it many times on my first day. My full screen has multiple windows with different uses. Being a new grad will slow me down even more when I start seeing patients. My employer said there's really no formal orientation offered for the software. Any suggestions?

Thank you!

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Specializes in Internal Medicine.

It's hard for me to say, it would take at least a few days depending on how much or how little you have to do in it. I got familiar with it as a student in the same facility I am at now. When I was a student just watching my boss use the software got me familiar with it, then when I started seeing patient independently I got more familiar. To be blunt I still don't have a clue how to use 75% of the functions of the software.

I typically just open the patients chart for the daily populated list. Review the previous visits if needed (which is the little scroll down menu on the right side). Review relevant labs which are usually also populated in the right side under DRTLA. From there I fill in the ROS, assessment, and diagnosis. If it's an established patient you can click the drop down menu under each respective heading and keep the same ROS, Assesment Data, and diagnosis, tailoring as needed. In treatment you can prescribe whatever you need and send it out, order labs/imaging, and make referrals. This is also where I will also write little notes about my POC in case another provider sees the patient next in our office.

The last thing I do is code my visit, which you can do when you go to "visit code" at the bottom of the screen, where you can also put when you want them back.

Outside of my assessments and treatments, the MA's and billing people mess with the other functions. My boss also had premade templates for me when I started so I couldn't tell you how to mess with that.

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It's hard for me to say, it would take at least a few days depending on how much or how little you have to do in it. I got familiar with it as a student in the same facility I am at now. When I was a student just watching my boss use the software got me familiar with it, then when I started seeing patient independently I got more familiar. To be blunt I still don't have a clue how to use 75% of the functions of the software.

I typically just open the patients chart for the daily populated list. Review the previous visits if needed (which is the little scroll down menu on the right side). Review relevant labs which are usually also populated in the right side under DRTLA. From there I fill in the ROS, assessment, and diagnosis. If it's an established patient you can click the drop down menu under each respective heading and keep the same ROS, Assesment Data, and diagnosis, tailoring as needed. In treatment you can prescribe whatever you need and send it out, order labs/imaging, and make referrals. This is also where I will also write little notes about my POC in case another provider sees the patient next in our office.

The last thing I do is code my visit, which you can do when you go to "visit code" at the bottom of the screen, where you can also put when you want them back.

Outside of my assessments and treatments, the MA's and billing people mess with the other functions. My boss also had premade templates for me when I started so I couldn't tell you how to mess with that.

Thank you very much!!!! These are helpful. I will write these tips down. This is much better than nothing ;-)

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Specializes in Adult Nurse Practitioner.

I tried Practice Fusion for a few months, but found it more labor intensive to do what I wanted it to do. Anyway, it does link back and forth from major labs which is nice, but it does not do billing so you have to input the codes and your price independently THEN process it through an outside biller. They offer some compatible systems...some are fairly priced, some are quite expensive. This is why they can offer it for free! I also found it difficult in regards to eprescribe. I tried unsuccessfully to have drug dosages corrected, or at least to have the various doses available to no avail.

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