Becoming a Nurse Practitioner: Transition to Practice Tips
New graduate NPs often encounter a steep learning curve and face numerous demands. From navigating job interviews and contract negotiations to developing strong diagnostic reasoning skills, acquiring new knowledge, improving documentation practices, and grappling with imposter syndrome—it can feel overwhelming. If it’s any consolation, the fears, anxieties, stress, and nagging thoughts like “Am I really cut out for this?” are entirely normal and universally experienced. In other words – we all go through the same challenges. This is what inspired me to create the NP Reasoning education platform – I want to help you, as a nurse practitioner, feel confident with your clinical reasoning skills.
Now, with over two years of full-time practice under my belt, I’ve had the chance to reflect on what I wish I had known as a new graduate. Many NP students and new grads have encouraged me to write on this topic, so I’ll address 5 common questions and challenges that we face as new NPs.
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1. Documentation for the NP: How can I get better (and faster) at charting?
Documentation is a critical yet time-intensive part of our workflow. Since most charting systems are electronic, it’s essential to familiarize yourself with your electronic medical record (EMR). Take the time to learn shortcuts, and explore how to use stamps or charting templates, as many EMRs now offer these features.
With the advent of AI scribes—digital tools designed to automate administrative tasks like documenting patient encounters—documentation is evolving. While not yet universally adopted, AI scribes are likely to play a significant role in the future. However, it’s important to remember that they can’t replace clinical reasoning; we still need to evaluate patients and develop our own treatment plans.
Personally, I’ve found charting templates invaluable for guiding common patient presentations. While not foolproof, they save time, help ensure I don’t overlook key questions and support my workup for various diagnoses. Over time, I’ve created hundreds of templates tailored to common family medicine presentations. When I learn something new about a presentation, I’ll edit the template to reflect updated knowledge.
For further reading on charting tips, check out my post on Documentation Essentials.
2. Inbox Management for the NP: How do I get better (and faster) at managing my inbox?
When we transition to practice, we quickly realize the huge task of managing the constant influx of inbox items: test results, consultation reports, prescription renewals, patient requests, forms to complete, and more. Just as with efficient documentation, it’s crucial to familiarize yourself with your EMR and its features. Many EMRs include tools designed to streamline tasks for providers (at least in theory).
It can also be helpful for clinical teams to periodically review which inbox items tend to slow people down. Identifying these bottlenecks can lead to process improvements and better delegation of tasks. Let me share a few examples from my own experience.
#1: Communicate with patients via email
Our EMR includes the capability to email patients securely, which has been a game-changer for communication. We obtain email consent from all patients, typically to share test results, send forms, or provide other relevant information. This consent is clearly highlighted in the chart for all clinicians to reference. Many EMRs have this capability now (but not all settings use it).
During each clinical encounter, I make it a habit to confirm whether patients consent to receiving test results or other clinical information via email—particularly for updates that don’t require an in-person or virtual visit, such as normal bloodwork results. This practice has saved hundreds of phone calls and significantly improved workflow. From my experience, patients appreciate this form of communication, as it eliminates the need to call the clinic for updates.
Additionally, many patients consent to receive lab and diagnostic imaging requisitions via email. If I plan to order any tests during a clinical encounter, I make sure to get their consent for this too.
#2: Get help from your team
In the beginning, you may feel inclined to handle everything yourself, and it can be challenging to ask for help. However, I’ve learned the importance of delegating tasks to avoid burnout, especially when you’re part of a team. Delegation is a skill that takes practice, but it’s essential for maintaining balance.
For example, I frequently delegate tasks to our RN or RPN, such as following up with patients about test results. Understanding the scope of practice for each team member and knowing what they’re comfortable handling is integral to effective delegation. For non-urgent test results, e.g. low vitamin B12 levels, I often forward the task of following up with a patient to our team nurses (via an EMR message), including clear instructions and supplementation guidance.
Leaving detailed notes/instructions not only streamlines the process for the nurses (or other team members) but also minimizes back-and-forth communication, making the workflow smoother for everyone involved. Delegating appropriately helps distribute the workload while ensuring patients receive timely care.
#3: Make notes about test results in the patient’s chart
We’re often inundated with what feels like hundreds of test results daily, making it easy to miss something or fail to follow up appropriately. To streamline my approach, I create a note in the chart as soon as I review the results. In this note, I include the date of the lab results, any normal or abnormal findings, whether the results align clinically with the reason for the test, and a follow-up plan (e.g., additional testing, patient follow-up, forwarding results to a specialist, etc.).
This method has multiple benefits:
If I have a follow-up appointment with the patient, I can copy the note into my documentation.
Nurses or other staff handling follow-up communication with patients can read through my reasoning and plan.
It prompts me to reflect on and fully process the results.
For tests requiring future monitoring (e.g., repeating an HbA1c for a patient with diabetes), I set an electronic reminder in the chart and post-date it to myself for follow-up (e.g. the message will come to my inbox in 3 months, and I can deal with it then).
Not all results require direct follow-up. For example, if a pap test returns normal, I’ll make a note in the chart: “Normal Pap—nursing or administrative staff can inform the patient” so that staff can confidently relay the information if the patient calls. Alternatively, I might email the patient directly with their results (if consent is on file).
#4: Set automatic reminders in the patient’s chart
As mentioned earlier, if any diagnostic tests need to be repeated (e.g., a follow-up mammogram or a repeat CBC for anemia), I set a post-dated reminder in the patient’s chart to ensure timely follow-up. I also make it a point to obtain the patient’s consent in advance if I anticipate future diagnostic tests. This allows me to email them a test requisition or place an order automatically when the time comes.
Staying current with clinical guidelines is essential to avoid over-ordering tests and unnecessarily burdening both yourself and the patient. This ensures efficient care while adhering to evidence-based practices.
#5: Don’t be scared of forms
We often handle a variety of forms for patients, and having a streamlined approach to form completion can make this task much more manageable. For many forms, I require an appointment with the patient to review the details together, especially if I’m not familiar with their medical history. This ensures accuracy and completeness. When completing a form, ensure you have medical information to back up your claims in the patient’s chart. We are often asked to complete government forms (e.g. tax credit forms etc.) – patients won’t always qualify for these forms. Fill out the information you can and let them know it’s not up to you to make them qualify (you can only use data you have from their medical information).
If you encounter an unfamiliar form, don’t hesitate to ask a colleague for guidance or look up instructions online or elsewhere. It’s all about finding what works best for you.
Inbox management tips: Communicate with patient’s via email if you can, delegate tasks to team members, make notes about test results to save you time in the future, and set automatic reminders/messages in the patient chart so action items won’t be dropped in the future.
3. How do I explain my role as an NP?
Although the NP role is becoming more recognized, many patients are still unfamiliar with what we do. It’s our responsibility to explain our role and how it differs from that of physicians and other healthcare providers. Over the past two years, I’ve had the pleasure of welcoming hundreds of new patients to the clinic in which I work—some familiar with nurse practitioners and others not at all. I tell all new patients the following:
"I’m a nurse practitioner. I began my career as a registered nurse and, after several years, pursued advanced education to become a nurse practitioner. Here in Ontario (where I practice), nurse practitioners are able to evaluate and diagnose medical conditions, prescribe medications and treatments, refer patients to specialists, and perform a variety of procedures, such as skin biopsies and casting fractures. We can also complete medical forms. I provide care to patients of all ages. Like any provider, if I feel less confident or comfortable managing a condition, I’ll consult with a colleague or refer you to a specialist to ensure you receive the best care possible."
Everyone develops their own narrative, but this is the one I use in my practice. I’ve found it helps patients understand the scope of what NPs can do.
4. Tips for Managing Complex Patients
I have the luxury of following patients longitudinally in a family medicine setting - not all of us do depending on our role. When we meet a complex patient for the first time, it can feel overwhelming. We often can’t address all concerns in one visit - and that’s OK!
Tip 1: If you can’t tackle all concerns for a complex patient in one visit, make that clear with your patient. At the beginning of an appointment, I will often say something like, “What is your priority concern this visit? Let’s focus on that, and if there are other issues, we can re-book an appointment.” If a patient is frustrated that I can’t address every concern, I’ll give the following messaging: “I want to be thorough with each concern you have, so we can make an appropriate plan together. I won’t be able to do a good job if I rush through it.” Patient’s seem to appreciate this. We’ve all been in the situation where you start to address one concern during a visit, and with 1 minute to spare in the appointment another very important issue comes up. I find that clear messaging from the beginning of the appointment helps set the priority for the patient.
Tip 2: Sometimes it’s hard to have a concrete plan formed at the end of a complex patient visit. Sometimes we’re left with more questions than answers. If it’s a non-urgent issue and I’m unsure what to do, I make that clear with my patient. I might need to review their chart, or consult a colleague or specialist before figuring out next steps. I’ll something like, “I need to review your chart and do some detective work. I want to be thorough and clear on what our next steps are. I can’t give you a concrete plan right now, but I’ll get back to you as soon as I can.” Honesty builds trust!
Tip 3: If you feel overwhelmed in a visit and haven’t had a chance to review the patient’s chart, do what you can, and bring the patient back for a follow-up to clarify issues in a future appointment if needed. For example, I’ve seen complex patient’s for a visit, and have left feeling confused as to what to do next (Is this a new or old concern? Has it been investigated before?) I’ll set aside 5-10 minutes to do a thorough chart review and make an easily accessible list in the patient’s chart that I can reference later. I’ll take note of previous investigations and consultations. This process often clarifies a lot of questions I had during the visit. Often, an issue has been previously investigated, so this saves me ordering tests or consulting specialists, and I can focus on treatment. This is a huge time saver for future visits! It can feel like a lot of work up front, but it’s worth the effort! I’ve had to do hundreds of chart reviews, and honestly, it helps you learn a lot as a new NP. Be a detective!
Here is an example of how I review and document a chart review in my EMR:
Diagnostics:
ECG / December 2020 / left bundle branch block identified
Stress echo / December 2020 / no abnormalities identified
Thyroid ultrasound / November 2019 / 1 benign nodule identified, no abnormalities
Gastroscopy / October 2020 / chronic active gastritis, negative for H. Pylori, celiac and malignancy
Consultations:
Cardiology 2020 / seen for chest pain, diagnosed with non-cardiac chest pain, no need for further investigations
GI / Dr. X / October 2020 / normal endoscopy, recommended PPI therapy, no need for further investigations
5. NP Education: How do I stay up to date and continue to improve my clinical skills?
The sheer breadth of knowledge we’re expected to keep up with can feel overwhelming at times! The best way to stay current is by reflecting on what you encounter in practice. I often see new or less familiar clinical presentations, and the way I solidify that knowledge is by reading around the case. There are many reputable and free resources available online, as well as paid resources, that can help with this. While reading about random topics can be hard to remember, if you can correlate the information with a real clinical case, the knowledge usually sticks. This approach helps me recognize potential mistakes and helps me adjust my approach when similar cases arise in the future. This also helps hone your diagnostic reasoning skills. If we can’t reflect, we can’t improve.
It’s also important to get comfortable with diagnostic uncertainty. It is a normal and unavoidable part of practice. I’ve learned to embrace it. This is what inspired me to create the NP Reasoning newsletter. It helps me stay up to date on various family medicine topics, and I enjoy sharing this knowledge with my readers.
Overall, how you manage your practice is highly individualized—there’s no one-size-fits-all solution. You’ll likely need to experiment to find strategies that save you time and identify processes that may be too time-consuming. Adapting and refining your approach will help you find the balance that works best for your workflow and overall growth as a provider.
My Favourite Resources
Primary Care RAP (paid subscription podcast)
Up To Date (paid subscription)
The Hub – Family Medicine (University of Toronto)