3 tips to STOP charting at home as a nurse practitioner

Wouldn’t it be so nice to STOP charting at home as a nurse practitioner?

To actually create a better work-life balance. To actually have the energy to spend with our families. To have the time to take care of ourselves.

But with the current amount of documentation nurse practitioners are responsible for, it almost sounds too good to be true huh?

As the creator of The Nurse Practitioner Charting School, it is my mission to help nurse practitioners improve their charting so they can STOP charting at home. There are many charting tips and ways to improve time management as a nurse practitioner.

I teach all about them in The Time Management and Charting Tips Course. I want nurse practitioners to know it is possible to improve their charting. To be more productive at work. To not have to stay late at work or bring charts home everyday. This article will focus on 3 tips to SOTP charting at home. 

Identify challenges of getting charts signed. 

Getting to the root of the problem is the first step to STOP charting at home. Think about when nurse practitioners evaluate a patient for a fever. There are so many differential diagnoses that could cause a fever and it is the duty of the nurse practitioner to determine the correct diagnosis. Same is true when it comes to improve charting so nurse practitioners can STOP charting at home. 

I recommend nurse practitioners complete a time log during their work day. Write out exactly what tasks (or distractions) occur during the entire work day. Write out everything you do for every 15 minute time slot.

Then take some time and reflect on how your time was spent. Was there a task that took up a lot of time that could have been delegated? Was there a social distraction that could have been avoided? Was there an hour that your time was well managed? Identify what challenges developed and focus on one habit change at a time. This will help nurse practitioners to STOP charting at home. 

Implement smart phrases and templates. 

Smart phrases

This time saving tip has worked very well in my own primary care practice! I realized I was seeing a lot of the same types of patients. For example, upper respiratory illness, urinary tract infection, school sports physical, annual wellness exam, etc. I was spending so much time typing out the history of present illness, physical exam, and plan of care that were very similar for each of these types of patients. 

I developed smart phrases (also called dot phrases) that I could easily pull into the patient’s chart note. Smart phrases are commonly used words/phrases about a certain topic. For example, I have a smart phrase for discharge instructions for sinusitis: Take medication as prescribed. Continue OTC medications. Urine will be sent for culture, I will notify patient if any changes need to be made. Follow-up for worsening or persistent symptoms.

I also have a smart phrase for the procedures that I do. For example, I have a smart phrase I can easily pull into my documentation following an incision and drainage or a laceration with suture repair. It saves me so much time from having to recall the information. Smart phrases can help nurse practitioners STOP charting at home. 

Be sure to check out The Comprehensive List of Smart Phrases. There are 125 smart phrases already created that can easily be implemented into the chart note! 

Templates

Very similar to smart phrases, templates can help nurse practitioners STOP charting at home. Charting templates are the framework for an entire note. It can save so much time from having to type out/dictate the same information again and again.

For example, I have a template for the school sports physicals that I see. There are certain questions and physical exam that I do for sports physicals. So having the template already have the “normal” history of present illness, review of systems, physical exam, and plan of care saves me so much time. It is much easier to change anything that is abnormal than it is to start with a blank chart note.

I also have a template for an acute adult visit vs a well child check. Again there are so many different components in the physical exam and plan of care that I have two separate notes. Templates can save so much time and help you STOP charting at home.

**Word of advice: Don’t spend your time making too many charting templates. You may find that having too many templates causes you to forget about the resources. You may find that you actually don’t use all of the templates.

I have 5 templates that I really use: acute adult visit, chronic/wellness adult visit, acute child visit, chronic/wellness child visit, and school sports physical. It is easier for me to have these core templates, then I use smart phrases to make an acute visit specific to the chief complaint. Or I use smart phrases to make an adult chronic template into a preoperative history and physical. So make sure to create templates that are specific to your practice. 

Set yourself up for success.

The last tip in order to STOP charting at home is to ensure you set yourself up for success. I encourage nurse practitioners to make changes to their charting habits so they can save time and create a better work-life balance.

Setting yourself up for success ensures nurse practitioners gain the focus and momentum to continue to make changes. It is much easier to change a habit when we have the time, energy, and tools to do so. The goal is to make changing our charting habits easier to achieve. When we make our habits easier to stick with, we are more likely to find long term success.

For example, utilizing The Comprehensive List of Smart Phrases will help us save time because the smart/dot phrases area already created. Overcoming nurse practitioner burnout helps us to regain our passion and fulfillment in healthcare. Meeting our physical, mental, emotional health needs is important for taking care of ourselves before we take care of others. Asking our bosses for more admin time or additional support staff are examples of setting yourself up for success.

Finding support and community through The Nurse Practitioner Charting School can help nurse practitioners stay accountable. These tips will help nurse practitioners set themselves up for success so they can STOP charting at home. 

Need more help to STOP charting at home?

This article discussed three tips to help nurse practitioners STOP charting at home. Identifying challenges of charting, implementing smart phrases/templates, and setting ourselves up for success will help nurse practitioners create a better work-life balance. Chose one of these tips and focus on making the changes! 

If you are a nurse practitioner who is needing to make more changes to their charting, check out The Time Management and Charting Tips Course!

This online, instant access course will help nurse practitioners learn the tips and tools to chart accurately and efficiently so you can run on time during the workday and STOP charting at home!

Learn more at The Time Management and Charting Tips Course!

Also check out this past webinar I did discussion 3 tips to STOP charting at home??