Nurse practitioner documentation: 4 things Ruby did to save time charting!

Charting is an essential aspect of a nurse practitioner’s role, but it often comes with its fair share of frustrations. The endless hours spent documenting can be overwhelming, and many nurse practitioners find themselves sacrificing personal time to keep up. The good news is that small, strategic changes can significantly improve nurse practitioner documentation, making it more efficient and less burdensome.

In this blog post, I will tell you the story of Ruby.

Ruby is a family nurse practitioner and works in internal medicine.

Ruby was overwhelmed with charting and the tasks of a nurse practitioner.

Ruby was sick and tired of staying late at the office and spending her evenings and weekends charting instead of relaxing with her husband.

Ruby had a large backlog of open charts (over 100 unsigned chart notes) and was always overwhelmed.

Ruby had a lack of work-life balance and was on the verge of nurse practitioner burnout.

So, Ruby joined the STOP Charting at Home Membership. Through the online courses and group coaching calls, she learned how these small changes can lead to big improvements in nurse practitioner documentation!

Here’s her story!

Frustrations of Nurse Practitioner Documentation

For many nurse practitioners, charting is a dreaded task. It’s not just the time it takes—it’s the mental exhaustion that comes with it. The constant pressure to be thorough while balancing patient care can lead to nurse practitioner burnout. Here are some of the most common frustrations:

1. Time-consuming: Charting can take up a significant portion of your day, often extending well beyond your scheduled work hours as many nurse practitioners have to bring charting home. This leads to a lack of work-life balance, strain on personal relationships, and little time for self-care.
2. Documentation overload: The amount of information that needs to be documented can be overwhelming. From patient history to treatment plans, every detail must be recorded accurately, leaving little room for error. (Make sure to check out 5 Minute Chart Notes Course! This mini course will help nurse practitioners avoid the note bloat and create problem-focused chart notes that take less than 5 minutes to write).
3. Perfectionism: Many nurse practitioners feel the need to write detailed, perfect notes, which can be time-consuming and counterproductive. This perfectionism often leads to over-documentation, adding to the already heavy workload. This is a significant frustration with nurse practitioner documentation. (Make sure to check out 5 Minute Chart Notes Course).
4. Interruptions: Charting often gets interrupted by patient needs, phone calls, or social distractions, making it difficult to maintain focus and complete documentation efficiently. Then add on the medication refills, analyzing diagnostic data, reviewing past medical documentation, and the never ending patient messages.
5. Emotional toll: The emotional burden of caring for patients can make it challenging to sit down and document encounters. This can lead to procrastination and further delays in charting. Ultimately this can cause issues with nurse practitioner documentation such as a backlog of open charts.

These are many of the same issues that Ruby faced in her own practice. Ultimately the challenges of nurse practitioner documentation caused Ruby to stay late at the office, chart at home, and sacrifice her time on weekends, just to catch up. It’s no wonder Ruby was starting to experience nurse practitioner burnout!

On top of the mental, physical, emotional exhaustion, Ruby’s employer was frustrated with the backlog of open charts.

Small Changes That Make a Big Difference

Ruby, a family nurse practitioner, faced many of these challenges. However, after joining the STOP Charting at Home Membership, she discovered that small changes could make a significant difference in her charting process. Here are a few things she did to improver her nurse practitioner documentation.

1. Improve Smart Phrases

Smart phrases are a powerful tool in electronic health records (EHRs) that can save you time and ensure consistency in your nurse practitioner documentation. However, many nurse practitioners underutilize them.

Ruby found that by customizing her smart phrases to fit her most common patient encounters, she could streamline her charting process. She started by identifying repetitive documentation tasks and creating smart phrases that included all the necessary information. This not only saved her time but also ensured that her notes were thorough and consistent.

Tip: Take some time to review your smart phrases. Are they up to date? Do they include all the necessary details? Consider creating or modifying smart phrases for your most common patient scenarios to make charting faster and more efficient.

***Also check out the Comprehensive List of Smart Phrases for access to 125 already made smart/dot phrases you can easily copy and paste into your nurse practitioner documentation!

2. Create Problem-Focused Chart Notes

As The Nurse Practitioner Charting Coach, I strongly encourage nurse practitioners to create problem-focused chart notes. And we discussed this in the STOP Charting at Home Membership. Instead of documenting every single detail, Ruby learned to focus on the patient’s chief complaint and the pertinent positive and negative findings.

By honing in on the specific issue at hand, Ruby was able to create concise, relevant notes that were easier to complete. This approach not only saved her time but also made her nurse practitioner documentation more effective in supporting patient care.

Tip: Shift your focus from documenting everything to documenting what matters most. Problem-focused chart notes are not only more efficient but also more useful for patient care.

***Also check out my online course: 5 Minute Chart Notes. This program helps nurse practitioners avoid the note bloat and create problem-focused chart notes!

3. Set Boundaries with Patients

Another valuable lesson Ruby learned was the importance of setting boundaries with patients during a clinic visit. For example, many patients were wanting to discuss 7+ chief complaints within one visit. Unfortunately in the modern healthcare system, there is not enough time for nurse practitioners to properly address all of these concerns in one visit.

Setting these boundaries helped Ruby manage her time better and ensure she is addressing the most important concerns. It also helped her maintain a more structured workflow, allowing her to complete her nurse practitioner documentation more efficiently.

Tip: Clearly define the boundaries with your patient. For example you can say to the patient, “You have the next 15 minutes with me, what are your top two concerns we can address today.” If the patient brings up an issue at the end of the visit you can reply, “I want to give this concern the proper time and attention, please schedule a follow-up visit so we can further address it. These techniques help you maintain control of the patient encounter and will allow you adequate time to complete nurse practitioner documentation.

4. Belief It’s Possible

Perhaps the most impactful change Ruby made was a shift in mindset. Through the STOP Charting at Home Membership, she received encouragement and support from other nurse practitioners who faced similar challenges. This community helped her believe that she could improve her charting process and reclaim her time.

The power of believing in yourself cannot be overstated. With the right mindset, Ruby was able to implement the small changes she learned and see significant improvements in her documentation. She went from feeling overwhelmed to feeling empowered, knowing that she could make her charting process work for her, not against her.

Tip: Surround yourself with a supportive community and remember that small changes can lead to big improvements. Believe in your ability to make those changes and take control of your nurse practitioner documentation.

***Feel free to join the STOP Charting at Home Membership for a group of equally burned-out nurse practitioners ready to support one another!

Need Help with Nurse Practitioner Documentation?

If you’re a nurse practitioner struggling with documentation, know that you’re not alone. The STOP Charting at Home Membership offers education, support, and a community of like-minded nurse practitioners who understand your challenges.

In this membership, you’ll learn practical tips like the ones Ruby implemented to improve her charting process. You’ll also gain access to resources, templates, and expert advice that can help you reduce the time spent on documentation and improve the quality of your notes.

Imagine being able to leave work on time, knowing that your charting is complete. Imagine having more time for patient care, professional growth, and personal activities. These are just some of the benefits you can experience by joining the STOP Charting at Home Membership.

Don’t let charting control your life. Take the first step toward improving your nurse practitioner documentation by joining a community that supports and empowers you to succeed.

***Join the STOP Charting at Home Membership so you can get your time back!

Great Job, Ruby!

Improving your charting doesn’t have to be a daunting task. As Ruby discovered, small changes can lead to significant improvements in your nurse practitioner documentation. Whether it’s enhancing your smart phrases, creating problem-focused chart notes, setting boundaries with patients, or simply believing in yourself, these small steps can make a big difference.

If you’re ready to take control of your charting process and stop bringing work home, consider joining the STOP Charting at Home Membership. With the right tools, support, and mindset, you can transform your nurse practitioner documentation process and reclaim your time.