Charting Hacks for Nurse Practitioners
Sometimes charting makes me want to scream. When I work in the fast track area of the emergency department diagnosing ear infections, suturing lacerations and treating minor injuries, I quickly become frustrated with documentation. It seems that charting the patient interaction takes longer than the visit itself. Not to mention, documenting what seems like the same visit over and over again makes me certifiably crazy.
Some days I swear that if I have to document one more visit for back pain, I’ll walk right out of the hospital doors never to return. Other days, I vow I will quit charting for the remainder of my shift arriving early to work the following day to catch up. I never end up doing either of these things (OK, maybe the latter), but charting takes up much of my work day and can be a serious drain on enthusiasm for my job as a nurse practitioner. So, I use a few documentation hacks to help alleviate the burden.
1. Copy and paste like a fiend
When I sit down at my work station in the emergency department, one of the first things I do is open a Word document I keep on file containing the most common phrases I use in patient charts. Lines such as “discussed head injury follow-up precautions and instructions” or “return to emergency department if symptoms change or worsen” are all pre-populated on this document so I can copy and paste into charts as needed.
More up-to-date EMR systems may allow you to store commonly used phrases in the system itself, populating them into your chart with the click of a button. Taking the time to set up this feature, or to develop a commonly used phrases document, saves seconds on each chart which add up throughout your shift.
2. Take advantage of templates
Again, my hospital’s antiquated documentation technology doesn’t allow for the creation of templates, but many EMR technologies take advantage of this feature. As a nurse practitioner, you likely treat the same or similar medical conditions on a repeated basis. Create documentation templates for the most common conditions you diagnose. This way, the next time you diagnose a patient in your pediatric clinic with strep, for example, your chart is nearly complete with the click of a button. Simply add in a few details such as “right” or “left” and your chart is complete! Preparing templates is a tedious task, but your work on the front end will pay off in significant time savings.
3. Be consistent with abbreviations
Using abbrev.’s in your documentation is an obvious shortcut to completing charts. However, caution must be taken with abbreviations. Use these shortcuts consistently. Avoid using multiple abbreviations for the same word as this could land you in a legal conundrum later. Additionally, comply with hospital or clinic protocol with your chart’s language. Some facilities maintain a list of approved abbreviations to avoid confusion among providers in interpreting documentation. Adhere to this list.
4. Manage time with intentionality
Many nurse practitioners and physician assistants I work with lament that the work day doesn’t allow sufficient time for charting. So, they are left with a pile of virtual paperwork to complete at the end of each shift making for an exhausting day. If you find yourself in a similar situation, take a look at the flow of your work day. Can you reorganize to fit in a few minutes here and there to chart?
My favorite time-saving tactic is to keep a bit of an inconsistent routine with my patient flow. I may see 3 patients in a row without returning to my desk, place orders for each all in one fell swoop, then work on charts as I await test and imaging results. Throughout my shift I constantly analyze the most efficient way to accomplish the tasks at hand. Will grouping tasks differently free up your time? Think about how your patient care routine could be modified to create precious extra minutes for paperwork.
Documenting patient encounters is a necessary evil. It helps us as nurse practitioners provide consistent care, is required for billing purposes as wells as complying with government regulations, and protects us legally. While cutting corners in your documentation isn’t advisable, implementing time-saving hacks will help curb your charting burden.
What charting hacks do you use as a nurse practitioner?
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