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The NP Charting School- The one stop for all documentation needs.

4 Charting Tips for Nurse Practitioners: Document in real time

Charting Tips for Nurse Practitioners: Document in Real Time

The NP Charting School is here again with more charting tips for nurse practitioners! These charting tips will helps NPs create a better work-life balance and conquer burnout!

There are multiple reasons nurse practitioners should strive to finish documentation in “real time.” By “real time,” I mean signing the chart notes right after the patient encounter.

I know it can be very difficult to get this accomplished. Somedays are better than other days. Some days nurse practitioners can stay caught up with documentation and leave work at work.

Other days nurse practitioners struggle with getting charts signed, refilling medications, reviewing documentation, analyzing diagnostic data, and keeping up with patient messages. With the amount of tasks nurse practitioners need to do, it’s hard to stay on time.

It’s normal to have bad days and nurse practitioners should give themselves some grace. It’s ok to not be perfect. But the constant running behind schedule and bringing charts home can definitely take a toll on nurse practitioners.

This creates a work-life imbalance that makes us prone to nurse practitioner burnout. That is why The NP Charting School shares charting tips for nurse practitioners! Striving to finish chart notes in real time can tremendously improve nurse practitioner’s productivity and keep us motivated to work hard.

Here are a few reasons nurse practitioners should work on signing chart notes in real time. 

  • Run on time during the day
  • Creates better patient satisfaction
  • Avoids having to stay late at the office or bring charts home 
  • Avoids overwhelm and added stress of always being behind
  • Allows for improved mental clarity 
  • Avoids having to chart at a later time and remember what the patient said or what the components of the physical exam
  • Increased productivity and motivation

Charting in real time diminishes feelings of overwhelm. Think about a time when you were running on time seeing patients. How did you feel? Were you productive and have clear mentation to focus? Were you in a better mood and relaxed when talking to the patient? Could the patient pick up on the positive vibes you were giving out? Charting in real time helps nurse practitioners in so many ways!

This article will look at several charting tips for nurse practitioners to document in real time!

Charting Tips for NPs: Utilize AI Medical Scribes.

One of the charting tips for nurse practitioners is to an artificial intelligence (AI) medical scribe. With the advancement of technology, a system such as Freed AI can do the hard work for you! Which means more time with the patient and less time charting!

Freed AI employs advanced natural language processing (NLP) and machine learning algorithms to streamline the charting process. Freed AI will actively listen to the conversation between the nurse practitioner and the patient. The Freed AI technology will then abstract the important information and create a chart note.

The nurse practitioner can then copy and paste the information into their electronic medical record (EHR). This eliminates a need for complex integration into the EHR. Therefore, nurse practitioners can begin using this technology without having to get approval from their clinic manage or waiting for IT to integrate.

Using Freed AI means you can easily finish a chart note right after the patient encounter. This charting tip for nurse practitioners can be a tremendous benefit to the nurse practitioner! The note is essentially completed and ready for the nurse practitioner to copy and paste as soon as the patient leaves. Not to mention the nurse practitioner can be more present with the patient and avoid having to chart while in the patient room!

Freed AI can assist nurse practitioners with staying on time during the workday and getting all of the charts signed! The use of Freed AI medical scribe helps the nurse practitioner improve productivity during the day and helps APRNs avoid bringing charts home! If you would like to learn more about Free AI be sure to check out the link here.

Also use my affiliate coupon code: NPCHARTING for $50 off your first month of Freed AI!

Charting Tips for NPs: Utilize tools for quicker documentation.

Electronic health records can be cumbersome and frustrating when trying to document a patient encounter. However, there are a lot charting tips for nurse practitioners to create efficient documentation. Taking the time to learn your electronic medical record system and implementing these tools can help nurse practitioners document in real time! Here is a list you can use!

Charting templates:

Creating a template takes more time upfront but can save so much time in the long run. I have templates made for an acute visit for adults, wellness visit for adults, acute for pediatric patients, wellness for pediatric patients, and sports physical. Through my charting system, these templates pull over information such as past medical history, allergies, home medications, diagnostic data, etc.

The charting template also has a “normal” review of systems and physical exam. Therefore, I just have to update anything that differs from the “normals.” Templates save me so much time and are one of the amazing charting tips for nurse practitioners!

If you would like access to charting templates on topics such as: Comprehensive note, basic SOAP note, annual wellness exam, well child check, acute URI, ortho focused, and anxiety/depression, check out The Time Management and Charting Tips Course through The Nurse Practitioner Charting School (the one stop for all documentation needs created specifically for nurse practitioners).

Smart phrases:

Similar to templates, smart phrases are pre populated text of commonly used phrases. For example, if you are a nurse practitioner working in dermatology and you constantly provide patient education about treatment of eczema, you can easily create a smart phrase. All the nurse practitioner would have to do is compile the commonly used education instructions and create a smart phrase into their charting system.

The nurse practitioner would use the smart or dot phrase and the pre populated text would easily pull into the chart note. This is one of the charting tips for nurse practitioners that saves a ton of time!

Click here if you would like more information on The Nurse Practitioner Charting School’s Comprehensive List of Smart Phrases. The Comprehensive List includes access to over 100 smart phrases for anything from acute visits/complaints, chronic problems, women’s health, mental health, pediatrics, wellness exams, procedures, and so much more!

Voice recognition systems:

Many nurse practitioners used to utilize dictation and transcription systems to help them save time when documenting. The nurse practitioner would talk into a phone or recorder the entire patient note. They would list out the history of present illness, past medical history, home medications, physical exam, diagnoses, and plan of care. A transcriptionist would then type out the information into a chart note. One of the downfalls of transcription is the fact that it is difficult to complete chart notes in real time. The process of transcription can take a few hours (or days).

Technology has allowed an updated system, voice recognition. Nurse practitioners may have heard about the brand Dragon Medical One. This voice recognition system is created specifically for medical documentation. The system recognizes medical terminology and creates less errors when transcribing what the nurse practitioner says. The voice recognition system can be very helpful because many nurse practitioners can talk faster than they can type.

Voice recognition systems are one of the helpful charting tips for nurse practitioners to finish medical documentation in a timely manner. 

**Also check out the above section about Freed AI Medical Scribe.

Freed AI

These charting tips for nurse practitioners can help APRNs save time charting by documenting in real time. I encourage nurse practitioners to discover which of these charting tools can help them stay on time during the work day. For other tips, tricks, and tools, check out Time Management and Charting Tips Course so you can stop charting at home!

Erica D the NP is a family nurse practitioner and The Nurse Practitioner Charting Coach. Erica helps nurse practitioners STOP charting at home! Erica created The Nurse Practitioner Charting School to be the one stop for all documentation resources created specifically for nurse practitioners. Learn more at www.npchartingschool.com

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***Full disclosure, this post contains affiliate links. I do receive a small commission if you purchase Freed AI. This is at no extra cost to you, but does help me continue to run The Nurse Practitioner Charting School.