New PMHNPs Charting Tips: One Habit I Wish I Learned Sooner
When I was a new PMHNP, I spent way too much time trying to find details that were discussed weeks or months ago. Over time, I realized there was a simple habit that made my documentation more efficient:
I started intentionally carrying forward the most important clinical history from note to note.
Not every detail needs to be repeated every time. But important information that impacts future treatment decisions should be easy to find. If your EHR does not have a way for you to access the patient’s psychiatric history and medication history (i.e. the psychiatric medications they have tried in the past that are unsuccessful), this is a must.
The information I stopped rewriting from scratch
For many patients, some parts of their psychiatric history remain relevant across multiple visits.
Examples include:
Previous medication trials and outcomes
Medications that were ineffective or poorly tolerated
Reasons medications were discontinued
Significant psychiatric history such as suicide attempts, self harm, or violence towards others
Prior psychiatric hospitalizations
Important medical history affecting psychiatric treatment
Previous treatment goals or patient preferences
Having this information easily accessible saves time and helps prevent important details from being overlooked.
Why this matters for new PMHNPs
Early in your career, it is easy to feel like every note needs to be a complete retelling of the patient’s story.
But good documentation is not about writing the longest note.
Good documentation helps communicate:
What is important about this patient’s history?
What treatments have already been tried?
Why are we making this treatment decision?
What information will the next provider need to understand the plan?
A well-organized chart tells the patient’s story without requiring someone to dig through years of notes to find it.
Clicking through years of notes every visit takes time.
Here’s what I do:
At the end of my note, I keep a quick summary of the above information and update it as needed. Adapt this approach to your organization’s documentation policies/EHR workflow.
Yes, it’s an extra couple of clicks at the beginning to create this, but it will save you from having to search through multiple past notes every time you see the patient going forward. This means more time focusing on the patient in front of you. Additionally, if another Psych NP takes over the patient later on, this approach will make it much easier for them for them to get a snapshot of the patient’s history.
Final thoughts for new PMHNPs
Learning efficient documentation is one of the biggest adjustments when you are starting out as a psychiatric mental heath nurse pracitioner.
Your focus should be on creating documentation that is accurate, clinically useful, and easy to follow. The small habits you develop early in practice can make a huge difference in your confidence, efficiency, and ability to provide thoughtful care.
Explore our resources for more tips for the new PMHNP starting out in practice.
