4 charting tips for new nurse practitioners

Are you in need of charting tips for new nurse practitioners?

Charting as a new nurse practitioner can feel incredibly overwhelming. Not only are you all of a sudden in charge of diagnosing and treating patients, you also have to ensure you have the correct information in the chart note. You have to choose the correct evaluation and management code to properly bill for the patient visit. And you have to cover your a** and avoid legal implications. All well simultaneously managing your time and avoiding nurse practitioner burnout. 

Side note: I have seen both new nurse practitioners and experienced nurse practitioners struggle with the time management and charting tips needed to avoid staying late at the office, STOP charting at home, and improve their nurse practitioner work-life balance. You are not alone!

Check out The NP Charting School’s blog page for time saving and charting tips for new nurse practitioners !

The frustrating thing about charting as a new nurse practitioner is the fact that we were not properly taught in school. From my own experience, as well as talking to all kinds of healthcare providers (physicians, physician associates, other nurse practitioners), most healthcare providers are ill prepared for charting in the real world. Come to find out, documentation is such an important part of the job and APRNs should learn these charting tips for new nurse practitioners!

Nurse practitioners document a patient encounter for three reasons: Continuation of care, billing and coding, and for legal reasons. Nurse practitioners need to summarize the patient visit for when the patient follows-up, sees another provider in the office, or is referred to a specialty provider. 

APRNs have to remember that healthcare is a business and nurses practitioners chart and correctly code for services rendered. The code is then used to bill the insurance company. NPs need to generate income to continue to provide services and treat patients. Nurse practitioners also have to document the correct information and protect themselves against a malpractice lawsuit. 

Through my work as The Burned-out Nurse Practitioner I have seen the negative effects the stress of charting can cause. I have seen new and experienced NPs struggle with nurse practitioner burnout as a result. 

So new NPs should utilize these charting tips for new nurse practitioners to improve their charting and work to avoid nurse practitioner burnout? We will discuss a few tips in this article.

Charting tools for new nurse practitioners

The difficult thing is that RN charting greatly differs from NP charting. Many nurse practitioners end up documenting like a RN. Many tend to over chart and don’t know how to create problem focused visits. They also do not know all the tools and tricks that can be utilized. We will discuss a few of charting tips for new nurse practitioners.

Utilizing charting tools- Templates

Charting as a new nurse practitioner can be made easier by utilizing the electronic medical record tools. For example, creating a template of commonly seen diagnosis can save the nurse practitioner a lot of time.

If you are a new nurse practitioner, working in an urgent care, you will likely see the same 10 diagnoses. Upper respiratory illness, musculoskeletal pain, pharyngitis, nausea and vomiting, conjunctivitis, fever, bronchitis, etc. A template made for each of these diagnoses can save the new nurse practitioner a lot of time.

Depending on your charting system, the template will likely include a “normal” review of systems,  physical assessment, and plan of care. When this information is pulled through to the chart note, all the new nurse practitioner has to do is update any patient specific information. These charting tips for new nurse practitioners are also valuable for experienced nurse practitioners!

Utilizing charting tools- Smart phrases

Smart phrases are words or phrases that are commonly used. For example, education of non-pharmacological treatment of type two diabetes, plan of care for a UTI, common side effects of a medication, when to follow up instructions, etc.

These smart phrases can easily be pulled into the charting system and save the nurse practitioner so much time again, and again by not having to document the same commonly said phrases. (Get access to over 100 smart/dot phrases in The Comprehensive List of Smart Phrases by The NP Charting School)!

Time management as a new nurse practitioner

Transitioning into a nurse practitioner role can be very overwhelming. APRNs have so many additional tasks we need to address. First off, NPs assess, diagnose, and treat patients. We then document our findings. Add on the additional responsibilities: reviewing medical documentation, analyzing diagnostic data, medication refills, and the never ending patient messages.

Many new nurse practitioners are overwhelmed by these unexpected tasks. Whatever work is not finished at the office likely has to be taken home for nurse practitioners to complete. This creates a lack of work-life imbalance and is a serious risk factor for developing nurse practitioner burnout.

Both new and experienced NPs can struggle with managing their time and implementing some time saving charting tips- you are not alone!. Read The NP Charting School’s blog page or check out The Time Management Charting Course to learn more about how to document accurately and efficiently so you can STOP charting at home.

Ask lots of questions as a new nurse practitioner

New nurse practitioners are not expected to know all the right answers. Medicine is always changing and developing new treatment guidelines.

As a new nurse practitioner, it is important to identify your resources (i.e. Up-To-Date, Epocrates, and continuing education courses). Also identify a supervising provider or more experienced provider so you can discuss patient specific cases. Ask other providers in your network about their charting habits and time saving tips.

Become familiar with your billing and coding resources. Even if as the nurse practitioner you chose the Evaluation and Management code, there is generally a billing and coding expert available if needed. Ask the experts questions. Ask them to review a chart note and give insight if you are choosing the correct Evaluation and Management code. Complete continuing education courses such as Billing and Coding for NPs or identify additional resources online.

As a nurse practitioner, you are responsible for assessing, diagnosing, and treating the patient as well as documenting and coding properly. NPs (new or experienced) should be informed and empowered to do the best job they can as a provider. Utilize these charting tips for new nurse practitioners and gain confidence is to ask questions and use your resources!

Give yourself grace as a new nurse practitioner

Working as a new nurse practitioner can be incredibly overwhelming. It is a significant learning curve to transition from being an expert as a RN to a novice as a nurse practitioner. There are so many differences in the two roles.

New nurse practitioners need to give themselves grace. If you don’t do it perfectly the first time, it’s Ok. Practicing as a nurse practitioner is both a science and an art.

We have to be ok with not doing everything perfectly. We have to be ok with the feelings of imposter syndrome– trust me both new AND experienced NPs struggle with these negative thoughts and insecurities (myself included!).

We have to be open to learning throughout our entire career. New nurse practitioners have to accept their chart notes will not be perfect. We have to accept we need to learn how to chart because most NP schools do not teach students how to chart in the real world. Implement these charting tips for new nurse practitioners and give yourself grace when it comes to charting and practicing!

I hope these charting tips for new nurse practitioners helpful!

When it comes to charting, The Nurse Practitioner Charting School is the one stop for all documentation resources created specifically for NPs! Check out the blog page for helpful charting tips!

Also checkout the paid courses: Time Management and Charting Tips, Billing and Coding, Legal Issues with Charting, and Charting as a NP Student. 

New nurse practitioners can sign up for a jumpstart list of these smart phrases to save time charting!