Have you ever thought about the reasons nurse practitioners chart?
Documentation is such an important concept of practicing as a nurse practitioner. It is what nurse practitioners spend hours doing everyday. Charting can seem redundant and tedious, yet it is vital (pun intended) for our work as nurse practitioners.
Medical documentation gives a snapshot of the patient encounter. A chart note should have a chief complaint (why the patient is being seen by the nurse practitioner). Then a history of present illness (further explaining the chief complaint).
Many chart notes then list out the past medical history, surgeries, allergies, mediations. The nurse practitioner may then document a problem focused review of systems and physical exam. Vital signs and diagnostic data are also included. The chart note then ends with a plan of care created by the nurse practitioner. As you can see, a nurse practitioner chart is so important for the care of the patient!
There are essentially three reasons nurse practitioners need to document a patient encounter: Continuation of care, billing and coding, and avoiding legal implications. Let’s break down these three reasons.
1. Nurse practitioners chart for continuation of care
Documenting a patient encounter for continuation of care purposes is very important. Multiple healthcare providers: our colleagues, specialty providers, nurses, allied health professionals, case managers, etc., need to know about the patient. Nurse practitioners chart the specific visit to give an overview of the patient condition.
That is why nurse practitioners document the history of present illness, review of systems, objective data, physical exam, diagnostic tests, and plan of care. So many healthcare providers use our documentation to determine the status of the patient. Continuation of care is an important reason nurse practitioners chart!
Continuation of care is key for multiple reasons. Clear documentation can improve the safety of the patient (i.e. listing allergies, adverse reactions, etc.). The charting may identify the significance of the patient’s condition (i.e. identify how many COPD exacerbations in the past year). It also helps to avoid any duplicate diagnostic tests (cardiology won’t have to repeat EKG, labs if provided).
When the patient follows up with you as the nurse practitioner, you need to remember the treatment plan or medications you prescribed. If you refer to orthopedics, the provider needs to know the HPI, physical exam, diagnostic tests, previous treatment plan, etc. Charting gives us that quick snapshot of the patient’s status and previous care.
2. Nurse practitioners chart for billing and coding
Healthcare is a business. Businesses need to generate revenue in order to sustain. The role of the nurse practitioner is to assess, diagnose, and treat the patient. But the nurse practitioner also needs to choose the correct Evaluation and Management (E & M) Common Procedural Terminology (CPT®) code for the patient encounter. These codes are then submitted to the insurance company to charge for the services rendered.
A knowledgeable nurse practitioner should be able to choose the proper E & M code to accurately charge the patient/insurance company for the work that was completed. This is an important reason why nurse practitioners chart!
A nurse practitioner who does not know how to properly choose the correct E &M, may be under coding or not adding codes for additional services. This can significantly impact the income produced by the clinic.
Even if the nurse practitioner does not directly link a code to the patient visit but has a coding expert do it for them, the nurse practitioner should at least have an idea of that code.
It is the nurse practitioners job to ensure they are doing their part to bring in revenue to the business. Differing from the RN position, APRNs play a major role in income generation for the healthcare institution.
If you would like more information about properly coding a patient encounter check out this course: Billing and Coding as Nurse Practitioners.
3. Nurse practitioners chart to avoiding legal implications
Nurse practitioner documentation will be used in a litigation process. The chart note provides information for the malpractice attorneys. If a case is opened years after the event occurred, most providers will not remember all the details, that is why the chart note is so important.
Nurse practitioners should ensure the chart note (and how they practice) will positively support them in a malpractice case. Medical documentation is used during any type of legal issue or malpractice case. That is why it is so important for nurse practitioners chart notes to be accurate and professional.
For more information on protecting yourself from legal implications, checkout this course: Legal Issues with Charting.
These three reasons why nurse practitioners chart show the importance of learning how to document. Nurse practitioners chart a patient encounter and it is so important for the ongoing care of the patient.
Unfortunately, many nurse practitioner schools fail us in learning how to actually chart in the real world. Many nurse practitioner students do not gain the knowledge of how to chart, properly bill and code, or protect themselves from legal implications.
This is why I created The Nurse Practitioner Charting School. To teach nurse practitioners how to chart accurately and efficient, choose the proper Evaluation and management CPT® code, and how to cover their a** when it comes to charting.
The Nurse Practitioner Charting School is the one stop for all documentation resources created specifically for nurse practitioners. The NP Charting School educates nurse practitioners on charting and gives them the confidence they need!
The NP Charting School offers free resources such as the a Jumpstart List of Smart/dot Phrases to save time charting or paid courses.
Feel free to check out The Nurse Practitioner Charting School for more information and charting resources!