7 charting tips for new nurse practitioner

Entering the healthcare field as a new nurse practitioner (NP) is both exhilarating and daunting. Among the many responsibilities that NPs face, one of the most critical is charting. Accurate and efficient charting not only ensures high-quality patient care but also protects the practitioner legally. For those who are just beginning their journey, this process can seem overwhelming.

But as The Nurse Practitioner Charting Coach, I am here to help new nurse practitioners! This blog post will delve into essential charting tips for new nurse practitioners and address some common fears that come with this crucial task.

Understanding the Importance of Charting

Charting is the systematic recording of a patient’s medical history and care. This documentation includes a range of data such as patient demographics, medical history, treatment plans, progress notes, and discharge summaries. Effective charting is vital for several reasons:

• Continuity of Care: It provides a comprehensive view of a patient’s health, ensuring consistent and coordinated care.
• Legal Protection: Detailed and accurate charts serve as legal documents in case of disputes or malpractice claims.
• Quality Control: Proper charting helps in monitoring the quality of care provided and identifies areas for improvement.
• Billing and Reimbursement: Accurate documentation is essential for proper billing and to ensure that services are reimbursed appropriately.

Common Fears of New Nurse Practitioners

Before diving into specific tips, it’s important to acknowledge the common fears new nurse practitioners often have about charting:

1. Fear of Making Mistakes: The worry of documenting incorrect information or omitting critical details can be overwhelming.
2. Time Management Concerns: Charting is time-consuming, and new NPs often fear it will take time away from patient care.
3. Legal Implications: The legal consequences of improper documentation can be intimidating.
4. Technology Challenges: Adapting to electronic health records (EHR) systems and other technology can be a steep learning curve.

Charting Tips for New Nurse Practitioners

To help mitigate these fears and improve your charting skills, consider the following charting tips for new nurse practitioners:

1. Familiarize Yourself with the EHR System

Electronic Health Records (EHR) systems are integral to modern healthcare. Take the time to thoroughly learn your facility’s EHR system. Many organizations offer training sessions or online modules that can help you become proficient.

New nurse practitioners can also ask their mentors or colleagues for charting tips. There are many helpful YouTube videos out there showing tutorials on how to use a EHR. The more comfortable you are with the system, the more efficiently you can chart. This is just one of the charting tips for new nurse practitioners.

2. Develop a Routine

Creating a consistent charting routine can greatly enhance efficiency. Some days it can feel impossible to create a work day routine, but putting your focus on the task at hand can help run on time. If you work in an outpatient clinic as a nurse practitioner, you are constantly bombarded by seeing patients, charting, refilling medications, analyzing diagnostic data, and the never ending patient messages. With the constant tasks that need completed, it can feel overwhelming.

Creating a routine is one of the helpful charting tips for new nurse practitioners. For example, address medication refills and calling patients about diagnostic tests first thing in the morning. Then when patients are scheduled, focus on only seeing patients and writing their chart notes right after the patient visit. Then right before “lunch break” address some of the patient messages. A structured approach ensures that nurse practitioners can improve their mental clarity and productivity.

3. Use Templates and Smart Phrases

Many EHR systems offer templates and macros that can simplify the charting process and are one of the helpful charting tips for new nurse practitioners. These tools can help you quickly input common phrases and standard information, saving you time and reducing the risk of errors. Templates can pull over a lot of the information such as past medical history, medication list, lab results, etc. These templates save a ton of time for nurse practitioners! Make sure to customize these templates to fit your practice style and patient population.

Smart phrases is one of the helpful charting tips for new nurse practitioner. I use smart phrases every single day! I work in primary care and I have smart phrases for the HPI for UTI, a comprehensive neurological exam, nonpharmacological interventions for a diabetic patient, etc. These examples of smart phrases are very different and new nurse practitioners can save a lot of time from having to constantly type out the same thing.

***Check out The Nurse Practitioner Charting School’s Comprehensive List of Smart Phrases.

4. Create Problem-focused Chart Notes

One of the top charting tips for new nurse practitioners is creating problem-focused chart notes. Many new nurse practitioners tend to over chart because that is what we did as RNs. When you are with a patient for a 12 hour shift, you document literally everything. Hourly rounding, what their BM looked like, how much they had to eat, if PT/OT worked with the patient, wound descriptions during a dressing change, etc. Many new nurse practitioners tend to do this as well.

Or maybe you learned how to chart in nurse practitioner school, but the practice chart notes had to be very detailed. Unfortunately, these comprehensive chart notes are not possible if you are seeing 20+ patients as day.

As a new nurse practitioner, ensure you create problem-focused chart notes. These short and sweet chart notes should have the necessary information but not have the “note bloat” that many new nurse practitioners struggle with. Clear and precise documentation improves communication with other healthcare providers and ensures that the patient’s care is well understood. Utilize these charting tips for new nurse practitioners to ease the frustration of starting out.

5. Beat the Backlog of Open Charts

Procrastination is a common pitfall in charting. And a backlog of open charts can feel endlessly exhausting. (Check out this article that discusses the Burden of Charting Backlogs). When there is constantly a backlog of open charts, the new nurse practitioner can feel overwhelmed. In turn the charting backlog inhibits their current workflow and causes them to run even further behind.

Addressing the burden of the backlog of open charts is one of the helpful charting tips for new nurse practitioners. Aim to complete your documentation as close to the time of the patient encounter as possible. This practice ensures that details are fresh in your mind and reduces the risk of forgetting important information.

***Here’s another article that shares more charting tips for new nurse practitioners: 6 Tips to Tackle to the Charting Backlog

6. Get Help on the Charting

Don’t hesitate to seek advice from more experienced colleagues. They can provide insights and tips based on their own experiences. Read chart notes written by other providers and get a feel for charting styles. Continue to work on your documentation skills and implement these charting tips for new nurse practitioner.

As The Nurse Practitioner Charting Coach, I share several charting tips for new nurse practitioners! Also make sure to check out my free training: 4 charting tips to get your time back as a nurse practitioner! You can use the link here to sign up.

I also have a course, How to Chart as a New Grad Nurse Practitioner which shares even more charting tips for new nurse practitioners! You can learn more here.

7. Give Yourself Grace

Starting out as a new nurse practitioner can feel very overwhelming. Working as a nurse practitioner is a significant learning curve from working as a registered nurse (RN). Not to mention that as a RN, you likely felt like an expert. Now as a new nurse practitioner you are a novice.

So one of the charting tips for new nurse practitioners is to give yourself some grace. The first year as a new grad nurse practitioner will feel overwhelming but you will learn soooo much! Enjoy the starting point and remember the joy and passion you have for taking care of patients.

Conclusion

Charting is an essential skill for new nurse practitioners, and mastering it takes time and practice. By implementing the charting tips for new nurse practitioners discussed above, you can improve your charting efficiency and accuracy. Remember, every experienced nurse practitioner was once in your shoes, and with dedication and perseverance, you too will become proficient in charting. Embrace the learning process, and soon, charting will become a seamless part of your practice.

Make sure to check out my course: How to Chart as a New Grad Nurse Practitioner. This course shares even more charting tips for new nurse practitioners and helps new grad nurse practitioners overcome the overwhelm of charting! Click here to learn more!