Get access to 125 smart phrases through The Comprehensive List of Smart Phrases brought to you by The Nurse Practitioner Charting School!
As nurse practitioners, documentation is the #1 time consuming and energy draining task we do on a daily basis. We spend a lot of time reviewing past medical documentation and creating chart notes after a patient encounter. We often spend 1-2 hours a night just trying to catch up on charting.
Through The Nurse Practitioner Charting School, I provide charting tips and resources to make APRNs jobs easier and ultimately get our time back. One valuable tool that can save so much time charting is using smart phrases as nurse practitioners.
What are smart phrases?
Smart phrases (also referred to as dot phrases) are commonly used words or phrases that can quickly be implemented into the electronic health records (EHRs). The predetermined text allows nurse practitioners to streamline the charting process.
These smart/dot phrases can include history of present illness, review of systems, physical assessment, plan of care, patient education materials, and more. Using smart phrases as nurse practitioners can save time, improve documentation accuracy, and allow APRNs to STOP charting at home.
Using smart phrases as nurse practitioners
Here are a few benefits of using smart phrases as nurse practitioners.
One of the primary benefits of smart phrases is their ability to expedite the documentation process. Nurse practitioners can create and use smart/dot phrases for commonly documented elements, such as physical exam findings, plan of care, procedures, or patient education. This speeds up charting, allowing more time for direct patient care.
Consistency and standardization.
Using smart phrases as nurse practitioners promotes consistency in charting. Smart/dot phrases ensure that certain key information is documented in a standardized format, making it easier for nurse practitioners to understand and follow patient histories and treatment plans.
With using smart phrases as nurse practitioner, there is a reduced risk of typographical errors, omissions, or inaccuracies in documentation. The predefined phrases help ensure that essential information is included, enhancing patient safety and care quality. This also helps nurse practitioners to help protect themselves legally.
Smart phrases facilitate clearer communication among healthcare team members. When everyone uses the same standardized phrases, it minimizes confusion and improves collaboration.
Customization of smart phrases.
Nurse practitioners can customize their smart phrases to meet specific practice needs. This includes tailoring phrases to their patient population, specialty, or unique documentation requirements. For example, using smart phrases as a nurse practitioner in primary care looks different than using smart/dot phrases while working as a hospitalist nurse practitioner in ICU.
Smart phrases can also be used for patient education. Nurse practitioners can create and insert educational materials into patient records, ensuring that patients receive consistent and reliable information about their conditions and treatment plans.
Using smart phrases as nurse practitioners can include billing and coding information. This makes it easier for nurse practitioners to ensure accurate coding for reimbursement purposes.
For example, when working in the ED, I use a smart phrase to document critical care time. It has the exact wording to justify and ensure the time meets the requirements for critical care time. This is an example of using smart phrases as nurse practitioners for billing and coding purposes.
For more information check out The Basics of Billing and Coding Course.
By eliminating the need to repeatedly type out common information, using smart phrases as nurse practitioners saves a significant amount of time. Nurse practitioners are able to focus more on direct patient care and clinical decision-making.
Adherence to best practices.
Nurse practitioners can embed best practice guidelines and evidence-based care recommendations within smart phrases, helping to ensure that their documentation aligns with current standards of care.
Using smart phrases as nurse practitioners is a valuable and time saving tool. Smart/dot phrases streamline documentation processes, improve accuracy, promote consistency, and enhance communication among healthcare team members. By customizing and utilizing smart phrases effectively, nurse practitioners can provide higher-quality patient care and optimize their workflow.
Tips for using smart phrases as nurse practitioners
Now let’s take a look at some tips for using smart phrases as nurse practitioners.
Tip 1: Familiarize yourself with the EHR system
Before you start using smart phrases, it’s crucial to become well-acquainted with the EHR system you use in your healthcare facility. Each system may have its own way to set up smart phrases, and understanding how to navigate and customize them will save you time in the long run.
Tip 2: Create a personalized library
When using smart phrases as nurse practitioners, customization is key. To get started, check out The Comprehensive List of Smart Phrases. It will be so easy to copy and paste these smart phrases into your charting system. You can then tailor your library to include phrases that you frequently use in your practice.
Smart phrases can range from common physical examination findings to specific treatment plans to patient education. Using smart phrases as nurse practitioners and having a personalized library will streamline your documentation process.
Tip 3: Keep it simple
While it’s tempting to create elaborate and comprehensive smart phrases, simplicity is often more effective. Use clear and concise language that accurately conveys the necessary information without overwhelming the reader. Avoid jargon or medical terminology that may confuse patients or colleagues.
Tip 4: Organize by specialty
Using smart phrases as nurse practitioners should be specific to your practice. If you work in a specialized field of healthcare, consider organizing your smart phrases by specialty. This will allow you to quickly access and utilize phrases that are most relevant to your patient population and practice.
Tip 5: Collaborate with colleagues
Don’t hesitate to collaborate with your colleagues to develop and share smart phrases. This can be particularly beneficial when working in a team-based healthcare environment, as it ensures consistency in documentation and communication.
Tip 6: Regularly update and review
Medical practices evolve, and so should your smart phrases. Regularly review and update your library to reflect current guidelines, treatments, and best practices. This will help you maintain accurate and relevant documentation. If I find that I need to update a smart phrase, I will often take an extra 3 minutes during the workday to make the changes. It will save so much time in the long run!
Tip 7: Use smart phrases for other charting topics
Smart phrases aren’t just for documenting chart notes; they can also be valuable tools for other charting topics. For example, smart/dot phrases can be used for patient education. Create phrases that explain medical conditions, treatment options, and follow-up instructions in a patient-friendly manner. This can enhance patient understanding and compliance.
You can also use smart phrases within the patient messages function through your EHR. If patients often ask for medical advice through the patient messages, use a smart phrase explaining the need to be seen in the clinic.
Check out the Jumpstart List of Smart Phrases (free version) for examples of smart phrases to be used in patient messages.
Tip 8: Focus on quality, not quantity
Avoid the temptation to create an extensive library of smart phrases that you may never use. I have found a list of about a dozen smart phrases is sufficient. I made the mistake of creating too many smart phrases and then I forget that I have them available. The smart phrases I commonly use are for patient education following an URI, UTI, preoperative history & physical, procedures (incision & drainage, steroid joint injection, laceration with suture repair, skin biopsy, etc.).
To see the smart phrases for nurse practitioners I have created, check out The Comprehensive List of Smart Phrases. Instead, focus on quality and relevance. A concise and well-thought-out library will serve you better than an overwhelming one.
Using smart phrases as nurse practitioners can significantly enhance the efficiency, accuracy, and overall documentation process. By familiarizing yourself with your EHR system, customizing your smart phrase library, and following the tips outlined in this blog post, you’ll be well on your way to becoming a proficient user of smart/dot phrases.
Click here for access to The Comprehensive List of Smart Phrases.