There are many differences in the roles of a registered nurse vs a nurse practitioner.
And RN and NP charting is no exception.
The general role of a registered nurse includes direct patient care, physical assessment, medication administration, and carrying out orders. Registered nurses then document the patient’s assessment, care, and any orders completed.
On the other hand, nurse practitioners assess, diagnose, and treat patients. The documentation of the patient encounter includes these components.
It may not seem like significant differences in charting, but many nurse practitioners have a hard time adjusting to documentation in the new role. I have seen so many new nurse practitioners struggle with documentation because they do not understand the differences between RN and NP charting.
It is important for nurse practitioners to understand the differences of charting and use this knowledge to create better chart notes.
We will take a look at a few of the differences between RN and NP charting and some tips on improving our nurse practitioner chart notes.
Components of RN and NP charting.
Many nurse practitioners tend to over chart because that is the way we charted as a registered nurse. This “note bloat” creates thorough, yet longer, chart notes that take more time to complete. Nurse practitioners generally add more information than what is truly necessary. This overcharging originates from our documentation as a RN.
For example, in the hospital setting, RNs are with the patients for a whole 12 hour shift. It was the duty of the RN to document everything the patient did during that time frame. When did the patient go to the bathroom? How did they get to the bathroom? Did they ambulate independently or use an assistive device with nursing assistance? How much did the patient void? What did the bowel movement look like? What did the patient eat for breakfast, lunch, snack, dinner? What medications were administered?
Did the patient have any wounds? If so, what did the wound look like and what interventions were completed? Did the patient have any family or friends as visitors? Did the patient work with physical, occupational, speech, respiratory therapy? What specialty healthcare providers (i.e. hospitalist, cardiology, orthopedics, neurology, etc.) rounded on the patient? What were the new orders for that patient? And the list goes on and on.
As you can see, RNs have A LOT to document. Registered nurses are used to being thorough in their documentation. Due to this prior experience and background, nurse practitioners tend to over chart. Nurse practitioners can save a TON of time if they adhere to problem focused visits. Yes, some patient visits such as internal medicine or comprehensive primary care visits are difficult to keep problem focused. But there are still some changes nurse practitioners can make to save time.
Working on straight to the point, problem focused chart notes is very important. I have seen so many new nurse practitioners struggle with adding in additional information. Understanding these differences between registered nurses vs. nurse practitioners charting can have a huge impact on clinical documentation.
Learn more about time management and charting tips for nurse practitioners so you can STOP charting at home.
Billing of RN and NP charting.
Documentation of a registered nurse differs greatly from that of a nurse practitioner. Most registered nurse’s documentation is not used to actually bill the patient’s insurance. Sure, registered nurses complete orders or administer medications which the cost of is billed to the patient’s insurance. There also may be some instances such as outpatient dressing change or a case management consult that can be billed. But for the most part, the registered nurse documentation is not directly used to bill for services rendered.
This is a major difference between RN and NP charting. The role of the nurse practitioner is to assess, diagnose, and treat the patient and then document in the patient chart. Nurse practitioners’ documentation includes history of present illness, past medical history, physical exam, diagnostic tests, diagnoses, and plan of care.
The patient encounter is then assigned a Current Procedural Terminology (CPT®) code based off the documentation. More specifically, these CPT® codes include an Evaluation and Management level. CPT® codes are also assigned to procedures or additional services the nurse practitioner performs.
These code are then used to bill the patient’s insurance company for services rendered. While the codes differ for inpatient, outpatient, emergency services, nursing homes, etc., the concept is the same. Nurse practitioners need to remember healthcare is a business and the nurse practitioner documentation is so important to bring in revenue for the healthcare institution.
Nurse practitioners need to make sure they are doing their part in ensuring the chart note summarizes the patient encounter and that the correct evaluation and management code is chosen.
Learn more about the basics of billing and coding as a nurse practitioner.
Use of RN and NP charting in a malpractice case.
If there are negative outcomes that happen to a patient and legal actions take place, ANY and ALL medical documentation will be reviewed. All medical documentation (registered nurses included) will be assessed.
And because nurse practitioners execute clinical decision making, their documentation will be vital. Nurse practitioners’ notes should have a complete overview of the patient (history of present illness, review of systems, physical assessment, diagnostic tests, diagnoses, and plan of care). It will be vital in a malpractice case. Nurse practitioners are at a higher liability due to the higher education and roles/responsibilities of a nurse practitioner.
No one is immune to a malpractice suit, but the nurse practitioner documentation will be reviewed. Nurse practitioners need to make sure the chart notes are accurate, legible, avoid any negative comments about the patient, and be easy to follow. Learn more about Legal Issues with Charting .
Nurse practitioners need to understand the differences between RN and NP charting. I have seen so many new nurse practitioners struggle with charting. Part of the reason is that nurse practitioners are not well informed about these differences in their formal education. That is why I created The Nurse Practitioner Charting School- to be the one stop for all documentation needs created specifically for nurse practitioners!
Learn more about The Nurse Practitioner Charting School!
P.S. If you are a student and want to know the basics of charting as a nurse practitioner student, check out: Charting as a Nurse Practitioner Student online course!