"Just Getting a Baseline" Is Not a Clinical Reason

Sep 29

You’re precepting a new NP who asks you to review her draft orders for a healthy new patient. CBC, CMP, TSH, lipid panel, maybe an EKG.

You ask what one of them is for. She says she is getting a baseline.

She is not being careless. She has watched experienced NPs and physicians order exactly this on nearly every adult who walks in, and nobody has ever told her why. The list gets passed down. The reasoning does not.

Baseline is a description of a result. It is not a reason to order a test.

What is wrong with ordering a baseline?

Nothing, when there is a clinical question behind it. The problem is when baseline is the entire answer. A test ordered to establish a baseline is a test ordered for a hypothetical future rather than for the patient in front of you right now, and that reasoning does not survive being said out loud.

I precept NP residents, and this comes up every single cohort.

An NP resident recently walked me through her draft orders for a healthy new patient. I asked her what each one was for. Not just the ones I would have done differently. All of them.

She could tell me what each test measured. So I changed the question to why she was ordering it.

The answer came back as getting a baseline. I asked what she needed a baseline for. She said in case it was abnormal in the future.

So I said it back to her. Everything on this list is not for today. It is for some hypothetical future in which this healthy patient gets sick.

That’s when she finally understood what the problem with the orders. And then she told me the truth: this is what she had seen everyone else order.

Is a standard list of orders actually wrong?

No, and that distinction matters. A standard list is often reasonable for a large share of patients, and the people who use one are not practicing badly. The failure is not the list. It is applying it without checking whether this particular patient is one of the people it fits.

If you have ever bought something sold as one size fits all, you know how this goes. It looks right on some people, hangs on others, and some cannot get into it at all.

A standard list may fit most of your patients and still be wrong for the person in your room. That resident's patient was healthy, and he had a history that called for particular consideration on a couple of tests she had not included.

Here is how the habit spreads. Whoever taught her that list may have solid reasoning behind every element of it. But what comes out in a busy clinic is this is what I order on everyone, because the reasoning is hard to compress and there is no time.

The trainee inherits the list without the logic. Then she teaches it to someone else the same way.

Why did watching your seniors work as an RN?

Because as an RN you were executing orders, not writing them. Understanding the rationale mattered enormously, and it mattered in a specific direction: you were the last check before a medication or intervention reached the patient. Learning by watching experienced nurses was reasonable, because someone upstream had already supplied the reasoning.

That position has changed, and the change is bigger than most of us are prepared for.

As an NP, you are the one authoring the orders. Behind you is a whole line of people whose licenses and certifications put them in a position to carry out what you wrote.

The person in first position has to understand why, because everyone downstream is executing rather than deciding. Their checks are real and they catch things, but they are checking against your reasoning. If there is no reasoning underneath the order, there is nothing for the chain to check against.

Copying what you saw is not wrong. It is just not sufficient anymore, because nobody upstream is supplying the why now. You are upstream.

This is one of the hardest parts of the role transition, and it is the part NP training gives you the least practice at. Students spend years learning to evaluate and carry out a plan. They spend far less time being the person who has to originate one and defend it.

I have a fuller explanation of why new graduates arrive feeling unprepared for work nobody taught them inThe NP Training Gap.

So when a new NP reaches for the list she has seen a dozen preceptors order, she is doing what worked for her entire career up to that point. The habit is not careless. It is built for the position she used to hold.

Do you need a baseline EKG?

Not on the strength of the word baseline alone. If a patient has no cardiovascular risk and no symptoms, a normal tracing tells you what you already expected. A future abnormal EKG would itself be the reason to act, and the absence of an earlier normal one does not change that decision.

Another preceptee asked me this directly. Do you order a baseline EKG on all your new patients?

I asked her what a baseline EKG is. She said it is so you have on record what their normal EKG looks like.

I asked, “Why would I assume it is anything other than normal sinus rhythm, when the patient has no signs or symptoms that suggest otherwise? And if it comes back normal sinus rhythm, what did I learn?”

I can see why a cardiologist might want one. I am not a cardiologist, and for a primary care patient with no risk factors and no symptoms, I could not name the question the tracing was answering.

There are new patients for whom I do order an EKG. Someone arriving on certain anti-seizure or antipsychotic medications, for instance, where I want to see the QT interval before I consider adding anything that could prolong it further.

That is not a baseline. That is looking for a specific feature that could hurt that specific patient.

When does a prior test actually help you?

When it was ordered for a real clinical question, so that later it can tell you whether a finding is new. The value is not in having a prior result on file. It is in being able to distinguish an acute change from a chronic one, which is what determines whether you act today.

Later that same day, with the same resident, we saw a patient in hypertensive urgency. An EKG was warranted, and it showed a fascicular block.

There was an EKG in the chart from several years earlier, ordered at the time because she had symptoms that could have been cardiac. The fascicular block was on that one too.

That changed the decision. The finding was not acute. She did not need the emergency department. She did need cardiology to evaluate it properly, and she got that referral.

Notice what did the work there. Not the existence of an old tracing. The fact that it had been ordered for an actual question, which is what made it interpretable years later.

It is not the baseline that tells you when to act. It is the change, or the absence of one.

An example, invented to show the shape of it

The following patient is invented, not a real person.

A 34-year-old man establishes care. No chronic conditions, no medications, no family history he knows of, no symptoms.

Version one: he gets the standard order list because he is a new patient. Four tests come back, all normal, and you have learned nothing you did not already believe. If one comes back mildly out of range, you now owe him a phone call, a repeat test, and possibly a referral, for a number you went looking for without a specific clinical question in mind.

Version two: you order based on what is actually in front of you, including age-appropriate screening, and you skip what has no clinical question attached.

Same patient. The second version is shorter, and every result in it means something when it lands.

What this has to do with your note

Every order you place turns into documentation, and the assessment and plan has to show that you evaluated realistic risk and decided how to intervene. An order you cannot explain is an order you cannot defend in writing, which is where the reasoning gap becomes a documentation gap.

This is what I told that resident when I could see her starting to doubt herself. “I am not asking because I disagree with you. I am asking because you have to write an assessment and plan, and what goes in it has to show your thinking. Being able to say why each test is there is what lets you defend it.”

There is a second payoff, and it is the practical one. We talked through what she would do if each result came back abnormal.

So when those results landed on a day I was not working with her, she already knew what came next. She had thought it through, discussed it, and written it down. The result arrived into a context instead of into a blank.

Some tests came off her list. Others went on. What she ended up with was built for that patient.

If your notes have drifted into long without being clear, the free SOAP Note Template is a clean starting structure.

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The habit worth building

You do not need to relitigate every order you place. You need two questions available to you at the moment you are ordering:

what question am I asking?
what will I do with the answer?

If you can answer those, order it. If the only answer is baseline, look again.

This is also the kindest thing you can do for whoever you precept. Say the reasoning out loud, even when it feels obvious, because it is not obvious to someone in her first month of using her license. The list is easy to pass down. The logic has to be spoken.

Does this mean order sets are the problem?

No. An order set built for a specific condition, which changes depending on whether that patient is at goal, is the opposite of a universal list. The problem is one list applied to everyone regardless of who is in the room. An order set tied to a diagnosis, with a question already attached to it, is doing the thinking rather than skipping it.

It is easy to read this article as an argument against ever having an order set ready in advance. It is not. Rebuilding a hypertension follow-up from a blank screen every time does not make you more thoughtful, it makes you less consistent, because the orders you remember to include at 8 AM and at 8 PM are different lists.

What separates the two is whether the orders respond to the patient.

A universal list does not. It is the same regardless of diagnosis or risk, which is exactly why nobody can explain it. A condition-specific order set already contains a clinical question, because it exists in response to a diagnosis this patient actually has.

The problem was never having a starting point. It was having a starting point that asks nothing.

An order set is still a starting point rather than a final answer. You subtract what does not apply and add what this patient's history calls for, the way that resident and I ended up doing.

The Chronic Disease Chart Smart Kit Bundle is built on that principle for the conditions that fill a primary care schedule, so the visits you repeat most have a structure that starts from the diagnosis rather than from nothing.

Chronic Disease Chart Smart Kit Bundle

Every order you place is a question asked on someone's behalf. The only thing worth insisting on is that you know what you asked.

Guidelines change, and this article reflects general practice as of September 2026. Screening recommendations differ by age, risk, and specialty society, so confirm current guidance against the issuing bodies and your own organization's protocols rather than relying on this piece.