As The Nurse Practitioner Charting Coach, I will teach you how to chart as a new grad NP!
I don’t know about you, but I did not feel prepared coming out of nurse practitioner school. Especially when it came to charting.
There is so much information to learn in nurse practitioner school. Most schools emphasize on learning the disease process, assessment, diagnosis, prescribing, and how to treat certain conditions. There is a focus on clinical decision making. All of these factors are very important when it comes to practicing as a nurse practitioner. But learning how to chart as a new grad NP is also crucial!
Lack of education on charting
I received one 45 minute lesson on the basics of what needs to go in a chart note and how to chose the correct evaluation and management code. I felt very confused and overwhelmed when I started out as a new grad nurse practitioner. I had to educate myself on charting and how to code visits.
I know other nurse practitioner students who did learn how to chart in NP school. But the SOAP notes they were expected to do were very comprehensive. These detailed notes take a lot more time and energy to complete. This is not possible to do when seeing 20+ patients a day. The nurse practitioners learned how to chart in NP school but it was not relatable for real-world practice.
There is a lack of education on how to chart as a new grad NP. Come to find out charting is an integral part of our practice.
Why nurse practitioners chart
Nurse practitioners have to document for three different reasons.
- Continuation of care. A chart note gives a picture of the patient’s signs & symptoms, condition, diagnosis, and treatment plan. If a patient follows up in clinic, is seen by another provider, evaluated in the emergency room, or seen by a specialty provider, the chart note provides the information about the patient. It is so important to have the documentation completed when caring for a patient.
- Billing and coding. When a patient is evaluated by the nurse practitioner, a chart note is completed. The documentation is then assigned certain Evaluation and Management codes. These codes are used to bill the patient’s insurance for services rendered. That shows how important it is to have an accurate chart note.
- Legal purposes. The chart note is the official record used in legal cases. If there was a negative outcome suffered by a patient, the documentation will be used in that malpractice case. It is vital (pun intended) to have the information complete.
As one can see, it is so important for nurse practitioners to feel comfortable charting. But with the lack of education in nurse practitioner schools, it is hard to know how to chart as a new grad NP.
Other charting struggles
A lot of nurse practitioners also struggle with the time management part of working as a nurse practitioner. A lot of new grad nurse practitioners are bombarded by the amount of work that needs to be done.
Not only do APRNs assess, diagnose, and treat patients, but they also document their findings. Then nurse practitioners have to complete medication refills, reviewing past medical documentation, analyze diagnostic data, and address the never-ending patient messages.
It is a lot of work for nurse practitioners to complete! And with the lack of education on how to chart as a new grad NP, many new APRNs struggle. A lot of new grad nurse practitioners end up staying late at the office or bringing charts home. This can disrupt their work-life balance and is a significant risk factor of nurse practitioner burnout.
How to chart as a new grad NP
As the Nurse Practitioner Charting Coach, I created a quick, online course to teach new grad nurse practitioners how to chart!
The How to Chart as a New Grad Nurse Practitioner Course will help you overcome the overwhelm and learn how to chart as a new grad NP!
This course will teach you the Top 5 Charting Tips to help new grad NPs go from overwhelmed to charting confidently!
- The basic parts of a chart note
- Tips for obtaining/documenting the history of present illness
- How to manage your time and create problem focused notes
- Gain the knowledge and confidence to improve your charting
- And so much more!
Learn more at How to Chart as a New Grad Nurse Practitioner!