Section 6.4: Locating Supporting Documentation Quickly

6.4.1 The “Why”: Speed as a Professional Discipline

In the preceding sections, you have learned what evidence to look for and how to interpret it. We now turn to a skill that is equally critical: locating that evidence with maximum speed and minimum wasted effort. In a high-volume prior authorization setting, where a specialist may be responsible for dozens of cases per day, efficiency is not a luxury; it is a core professional competency. The time you save on each case is time that can be devoted to another patient, another submission, another appeal. Ultimately, your speed directly translates into faster access to therapy for the patients who are waiting.

It is crucial, however, to distinguish between being “fast” and being “hasty.” A hasty review is one that cuts corners, misses details, and results in weak, easily deniable submissions. A fast review, the subject of this masterclass, is one that is built on a foundation of precision and process. It is the result of a systematic, repeatable workflow that eliminates extraneous steps and focuses cognitive energy only on high-yield activities. You become faster not by reading less, but by knowing exactly what to read and what to ignore.

This is a skill you have already begun to develop in your pharmacy career. The ability to manage a queue, triage tasks, and perform multiple checks under pressure in a busy retail environment is the perfect training ground for the focused discipline required in PA. This section will teach you to channel that ability into a structured workflow for data retrieval. You will learn to stop exploring the EMR like a tourist and start operating within it like a surgeon: with a clear plan, precise tools, and an unwavering focus on the objective. Every click will have a purpose. Every search will have a target. The result is a dramatic increase in your capacity and effectiveness as a PA specialist.

6.4.2 The Universal 5-Minute Chart Review: A Core Workflow

The foundation of efficiency is a standardized, repeatable workflow. While every case is unique, the process for investigating them can be remarkably consistent. The following “5-Minute Chart Review” is a universal playbook that can be applied to the vast majority of prior authorization requests. It is designed to be a systematic, high-speed pass through the EMR to determine if the core, high-yield evidence required for an approval is readily available. Mastering this sequence is the single most important step you can take to maximize your efficiency.

Masterclass Table: The 5-Minute Chart Review Playbook

Step	Time Allotment	EMR Tab(s) & Actions	Goal: The Evidence You Are Hunting For
Step 0: Pre-Flight Checklist	30 Seconds	Review the Prescription and Test Claim Rejection.	Confirm the exact drug, patient, and ICD-10. Understand the reason for the PA (e.g., “Step Therapy Required,” “Non-Formulary”). Have the case in your mind before you open the chart.
Step 1: Jurisdictional & Policy Check	60 Seconds	Tab 1: Face Sheet. Verify Name, DOB, Insurance. Tab 2: Problem List. Confirm primary diagnosis & code. ACTION (Monitor 2): Pull up the correct payer policy based on the drug and ICD-10 code.	Confirm you have the right patient and the right “rulebook” (policy). Quickly scan the policy’s main criteria to prime your brain for what you need to find.
Step 2: The Step-Therapy Sweep	90 Seconds	Tab 1: Medication List. Scan both Active and, more importantly, Discontinued/Inactive sections. Tab 2: Allergy List. Scan for any documented allergies.	Goal: Find evidence of failure/contraindication to preferred formulary agents. Are the names of the required step-therapies on the Discontinued list? Is there a documented allergy to a preferred drug?
Step 3: The Specialist Scan	60 Seconds	Tab: Consults. ACTION: Filter the notes list by the relevant specialty (e.g., “Cardiology,” “Oncology,” “Rheumatology”). Open the most recent note from that specialist.	Locate the single highest-value document in the entire chart. The justification for a specialty drug will almost always live in the specialist’s most recent assessment.
Step 4: The Targeted Strike	60 Seconds	Within the open Specialist Note. ACTION: Use the search function (Ctrl+F) with extreme prejudice. Do not read the note from top to bottom.	Goal: Extract the “money statements.” Search directly for the key data points identified from the policy in Step 1 (e.g., search for “LVEF,” “A1c,” “failed,” “progressive,” “joint count“). Copy/paste the relevant sentences and numbers into your text editor.

6.4.3 Playbook Deep Dive: Common PA Scenarios from Start to Finish

Theory and tables are useful, but efficiency is a skill built through repetition. In this section, we will walk through the 5-Minute Chart Review workflow in a narrative, play-by-play format for three common, real-world scenarios. We will simulate the thought process, the clicks, and the decision-making of an expert PA pharmacist operating at peak efficiency.

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Playbook 1: The GLP-1 Receptor Agonist (Ozempic for T2DM)

The Scenario: A prescription for Ozempic 1mg weekly for a 58-year-old male. The test claim rejects for “Prior Authorization – Step Therapy Required.”

The Clock Starts… NOW.

(0:00 – 0:30) Step 0: Pre-Flight Checklist. I have the Ozempic Rx in my queue. ICD-10 is E11.9, “Type 2 diabetes mellitus without complications”—a bit vague, but it’s what I have. The rejection explicitly says Step Therapy. My brain immediately thinks: “I need to prove failure or contraindication to metformin, and maybe a second agent like a sulfonylurea or DPP-4 inhibitor.”

(0:30 – 1:30) Step 1: Jurisdictional & Policy Check. I open the patient’s EMR on Monitor 1. Click the Face Sheet. Name, DOB, and insurance match the Rx. Good. Click the Problem List. I see “Type 2 Diabetes Mellitus (E11.9)” and “Hypertension (I10).” Diagnosis confirmed. On Monitor 2, I log into the payer portal, navigate to their clinical policies, and search for “Ozempic” or “GLP-1.” The policy, “Clinical Criteria for GLP-1 Receptor Agonists,” pops up. I scan the criteria: 1) Diagnosis of T2DM. 2) Trial and failure of, or contraindication to, a 90-day supply of metformin. 3) Most recent HbA1c > 8.0%. Perfect. I know my three targets.

(1:30 – 3:00) Step 2: The Step-Therapy Sweep. I click the “Medication List” tab in the EMR. I scan Active meds… I see lisinopril and metformin 1000mg BID. This is key: he’s currently on metformin. The policy requires failure. I click the “Discontinued” sub-tab. I scan the list… I see glipizide, stopped 2 months ago. Excellent, that’s likely the second agent. Now I check the “Allergy” tab. Nothing listed for metformin or any other diabetes drugs. So, my path is clear: I must prove failure of metformin and glipizide, not a contraindication.

(3:00 – 4:00) Step 3: The Specialist Scan. I click the “Progress Notes” tab. I see a mix of notes from Family Medicine and Endocrinology. I filter by “Endocrinology” to isolate the high-value target. The most recent note is from last week. I open it.

(4:00 – 5:00) Step 4: The Targeted Strike. The note is open on Monitor 1. The policy criteria are visible on Monitor 2. My text editor is ready. I don’t read the note. I use Ctrl+F. My first search is for “A1c“. The search jumps to the Objective section: “Recent labs from 2 days ago notable for an HbA1c of 9.1%.” BINGO. I copy that entire sentence and paste it into my text file. Next, I search for “metformin“. The search jumps to the Assessment & Plan section. I find the sentence: “Patient’s T2DM remains uncontrolled with an A1c of 9.1% despite maximum tolerated dose of metformin.” I copy that sentence. Now I search for “glipizide“. The search finds a sentence in the HPI: “Patient self-discontinued glipizide two months ago due to recurrent episodes of hypoglycemia.” I copy that sentence. It provides both the fact of discontinuation and the clinical reason.

(5:00) The Clock Stops.

Outcome: In five minutes, I have located every single piece of required evidence. My text file now contains the patient’s demographics, the qualifying A1c with its date, the statement confirming metformin failure, and the statement explaining the glipizide failure. The case is built. I am now ready to transfer this information into the payer’s portal, a process that will take another few minutes. The entire investigation is complete in less time than it takes to make a cup of coffee.

6.4.4 Advanced Techniques for When the Trail Goes Cold

The 5-Minute Review is a powerful tool, but it is designed for speed in cases where the evidence is well-documented and located in the usual places. What happens when you execute the playbook and come up empty? This is where an advanced investigator separates themselves from a novice. When the trail goes cold in the structured data (labs, specialist notes), you must know how to hunt for clues in the “unstructured” parts of the EMR.

Hunting in Unstructured Data: Nursing Notes & Phone Logs

The Scenario: The policy for an expensive anti-migraine CGRP inhibitor requires failure of two alternative therapies, one of which is topiramate. You’ve searched the Med List, and topiramate is not on the active or discontinued list. You’ve searched the specialist’s note, and it’s not mentioned. The trail is cold.

The Advanced Technique: Patients often report side effects or intolerances between visits via phone calls or patient portal messages. These communications are typically documented by nurses or medical assistants in separate “Telephone Encounter” notes or message logs. This is unstructured data, but it’s a goldmine for proving intolerance.

Your Workflow:

1. Go to the main Progress Notes or Encounters tab. Instead of filtering by “Office Visit,” look for filters like “Telephone,” “Patient Message,” or “Nursing Note.”
2. Open the search function for the entire chart (if available) or go through these notes chronologically.
3. Search for keywords. Don’t just search for “topiramate.” Search for “side effect,” “dizzy,” “can’t tolerate,” or “brain fog.“
4. You might find a nursing note that says: “Patient called to report that the topiramate started last week is causing significant cognitive slowing (‘brain fog’) and she is unable to function at work. She stopped the medication today. Message sent to Dr. Smith for alternative.”

This note is your smoking gun. It proves the trial, the adverse event, and the discontinuation, all in one place. You have just solved the case by looking where others would have given up.

The Hospital Discharge Summary: The Great Synthesizer

The Scenario: You are working on a PA for Entresto for a patient who was recently hospitalized for a heart failure exacerbation. The outpatient cardiology notes are confusing and don’t clearly state the LVEF or the reason for the switch from lisinopril.

The Advanced Technique: A hospital discharge summary is one of the most high-yield documents in the entire EMR. It is a comprehensive narrative written at the end of a hospitalization that synthesizes the entire course of events. It is designed to communicate the most critical information to the patient’s outpatient providers.

Your Workflow:

1. In the Progress Notes or Encounters tab, filter specifically for “Discharge Summary.“
2. Open the most recent one. This document is worth reading more thoroughly than a standard progress note.
3. Look for key sections like “Hospital Course,” which will explain the day-by-day events, and “Discharge Medications,” which will explicitly list the medications being stopped and started, often with the rationale.
4. You will likely find what you need in these sections: “The patient was admitted for acute decompensated systolic heart failure. An echocardiogram performed on day 1 showed an LVEF of 25%. Lisinopril was discontinued due to a rising creatinine and persistent cough. The patient was started on Entresto and has tolerated it well.”

This summary has handed you the entire case on a silver platter: the qualifying LVEF, the reason for the ACE inhibitor failure, and the initiation of the new drug. It’s the ultimate PA cheat sheet for any recently hospitalized patient.