Why Documentation Is Worth the Upfront Effort
Buchi Neita, PA-C, and Shanna Miranti, PA-C, open with a problem most APPs know too well: the mountain of open notes waiting at the end of a busy clinic day. Miranti admits she's almost embarrassed to say how many charts she has left to review, and their guest, dermatology PA Ellen Toneff, reframes the whole issue. Toneff, the clinical curriculum coordinator and lead APP trainer at Suncoast Skin Solutions, says she doesn't love paperwork — she loves what good charting does. It keeps patients safe, keeps the clinic flowing, keeps her MA happy, and keeps her from doing charts at home at night.
Her core message is a shift in timing. Much of the after-hours work happens because clinicians go back and chart retroactively. Toneff argues that time is better spent up front — learning the charting system and building notes that repopulate — so the note is already how you want it before you ever leave the room. As she puts it, documentation is 'an investment in your patients and yourself and in your free time.'
The Real Risks of Scanty Notes
Neita asks about the danger of thin documentation. Toneff points first to legal risk — if it's not in the note, it didn't happen — but she's just as concerned about care itself. If you don't care about your notes, your MAs won't either, and no one will own the record that tells the patient's story.
She also frames poor documentation as a continuity failure. Without a clear trail, you and your MA spin your wheels visit after visit, unsure where you left off. Her fix is vivid: leave breadcrumbs for yourself, for your MAs, and for whoever covers you next, so the next person can read the last note and know exactly how to move the patient forward—rather than trying to read your mind.
Let the EMR Do the Work: HPIs, Macros, and Learning the System
Toneff, an EMA user, is unapologetically curious about her charting system — she wants to click around and make her notes look their best. Her practical advice: you don't need an annual EHR conference to get good. Use the built-in resources. In EMA, click the community button or the help section for videos that run under five minutes, and read the practice-update pop-ups that appear every other month. Ask your MAs, too — they're the ones charting, so when they find something useful, adopt it.
She's a strong advocate for diagnosis-specific HPIs. Instead of pulling a generic follow-up that won't prompt the right questions, she points to targeted templates — a melanoma follow-up HPI, a biologics HPI, an isotretinone HPI — where typing in a specific medication pre-populates the most pertinent questions. That means the MA is already asking the right things before the provider walks in. Miranti underscores the point: it's the pertinent positives and negatives that matter, and generic templates often won't prompt them.
Building Protocols That Save Hundreds of Hours
The heart of the episode is protocols. Toneff says an hour spent building one can save hundreds of hours later. She keeps five isotretinone protocols alone: female pre-30-days, female start, female follow-up, male start, and male follow-up. To build one in EMA, she pulls in the diagnosis (acne, with morphology like inflammatory papules and pustules on the face, an associated diagnosis of high-risk medication monitoring, and a status of inadequately controlled), then builds out the plan — counseling blocks, birth control counseling if she prescribes it, prescription medication management, and the isotretinone monitoring section that tracks months of therapy, dosing, and cumulative dose.
Her counseling block is thorough by design: alcohol use, vitamin A supplementation, lab schedule, when to stop and call the office, iPLEDGE requirements, no blood donation, night-driving caution, two forms of birth control during treatment and for one month after. Crucially, she stresses that protocols are scaffolding, not straitjackets. It's far easier to alter a note than to start from scratch, and every note should still be adjusted to the individual patient — as she says, 'I'm an individual, I'm not a protocol.'
The Historical Summary Trick
Toneff's final tip is the EMA historical summary, found in the same dropdown as the HPI, populating just after the HPI in the note. She uses it for the things she never wants to miss — a history of melanoma, BCC, or SCC — so the reminder travels from note to note and neither she nor her MA has to dig through old charts to remember to ask.
Her example resonates: an isotretinoin patient won't be on isotretinoin forever, but a melanoma patient has that history every single time — and it's the kind of detail that gets buried among a hundred basal cells. The historical summary keeps the most important fact front and center at every visit.