Utilizing smart phrases in the hospital setting can help save time, increase efficiency, and improve the accuracy of your documentation.
If there is one thing certain in the hospital setting is that nothing is certain! Nurse practitioners who work in the hospital setting should expect the unexpected. When hospitalist nurse practitioners get to work and assess their scheduled patients, it may look like a calm, doable day. But then APRNs end up with 3 critical lab values that require attention, 2 early discharges, 1 rapid response, and new admissions coming through the door- all at the same time!
It takes a lot of mental and physical energy to work as a hospitalist nurse practitioner. This goes for APRNs that work in specialty care clinics AND also round on hospital patients. It is difficult to get used to the flow of a hospital setting.
This article will focus on how utilizing smart phrases in the hospital setting can help you save time charting!
What are smart phrases?
Smart phrases are pre-written phrases or sentences that can be quickly inserted into your electronic medical record (EMR) system. Smart phrases (also called dot phrases) are a block/combination of frequently used words that can be easily pasted into the chart note. Smart phrases are commonly repeated phrases, such as treatment plan/orders for atrial fibrillation with RVR or discharge instructions following a hospitalization of community acquired pneumonia.
Smart phrases can be implemented into every single practice area, primary care, urgent care, hospitalist or acute care, emergency department, cardiology, pulmonology, women’s health, mental health, dermatology, endocrinology, orthopedics….. you get the point.
Utilizing smart phrases in the hospital can save a ton of time by easily inserting these commonly used phrases into the chart note. This prevents the nurse practitioner from having to type out the same sentences multiple times a day. Utilizing smart phrases in the hospital setting saves so much time!
How can utilizing smart phrases in the hospital helps NPs.
Hospitalist nurse practitioners have multiple tasks they do on a daily basis. These tasks include: ordering and reviewing diagnostic tests, ordering medications, rounding on patients, updating patient’s family members, coordinating care with nurses and specialty providers, documentation, and billing.
Nurse practitioners that round on hospitalized patients are prone to burnout. The workload, decision making, and frequent interruptions can cause increased mental fatigue and stress for burned-out nurse practitioners. Many nurse practitioners struggle with completing tasks and leaving work on time. This can create a lack of work-life balance which worsens nurse practitioner burnout.
As mentioned, one of the tasks hospitalist nurse practitioners have to do is documentation. Hospital chart notes are often complex, addressing multiple conditions and comorbidities. This takes extra time for the nurse practitioner to create these types of progress notes. The good news is, there are ways to decrease the time needed to create a patient care note.
While every patient situation is unique, there are common diagnoses hospitalist nurse practitioners see. For example, some patients who have community acquired pneumonia require hospitalization. Patients who experience chest pain with risk factors of coronary artery disease often require additional monitoring and evaluation.
Hospitalist nurse practitioners can take these common diagnoses and create smart phrases. (Or nurse practitioners can utilize The Comprehensive List of Smart Phrases created by The Burned-out Nurse Practitioner through The Nurse Practitioner Charting School). Utilizing smart phrases in a hospital setting can save so much time.
Tips for utilizing smart phrases in the hospital setting.
Identify the most commonly used phrases.
Take note of the phrases you use most frequently in your documentation. These could include common phrases in the history of present illness, physical exam findings, and plans of care. Each of these commonly used phrases can be created as smart phrases in the hospital setting.
Create a library of smart phrases.
Once you have identified the most commonly used phrases, create a library of smart phrases in the electronic medical record (EMR) system. You can also ask your colleagues to share their own smart phrases to expand your library. Or utilize the Comprehensive List of Smart Phrases for Nurse Practitioners!
Don’t create too many smart phrases.
It may sound counter intuitive to not create too many smart phrases, but the reality is, if hospitalist nurse practitioners can actually have too many smart phrases. I recommend creating smart phrases for a common list of complaints and also having a generic smart phrase.
For example, nurse practitioners may want to create a smart phrase for a history of present illness for every surgery admitted to the hospital. As hospitalist nurse practitioners know, there are hundreds of different types of surgeries! It would take forever to create separate smart phrases for each of these surgeries! However, hospitalist nurse practitioners can create (or utilize the smart phrases in the hospital written in The Comprehensive List of Smart Phrases) for a generic surgery patient.
The hospitalist nurse practitioner can then change or add information to make the chart note specific to that patient. However, if you work as an orthopedic nurse practitioner, it may be beneficial for you to create smart phrases specific to the different types of orthopedic surgeries. Utilizing smart phrases in a hospital setting should be specific to the types of patients nurse practitioners see!
Use smart ques you will remember.
Once you implement the list of smart/dot phrases for your nurse practitioner practice, create the (.) portion so that you will remember. Nurse practitioners can create a ton of smart phrases, but if it is something you forget about, the list is not that helpful. Determine the shortcut you will use to implement the smart phrase. For example .exam will pull a normal physical exam into your note.
Pro tip: Create yourself a cheat sheet for quick reference!
Customize your smart phrases.
While using pre-written smart phrases can save you time, it’s important to customize them to fit the patient’s specific situation. Add details such as the patient’s name, age, and medical history to make the documentation more personalized. Hospitalist nurse practitioners can also utilize templates to have a lot of the information pulled from the patient’s chart.
Implement smart phrases into the EMR.
When it comes time to actually implement the smart phrases into your EMR, it can be difficult to know how. With so many different charting systems out there, it is hard to show nurse practitioners exactly how to add smart phrases. Ask the IT department for assistance. Discuss with a colleague who already uses smart phrases. Research tutorials on Google/YouTube.
You can always save the smart/dot phrases into a Google doc and take with you wherever you go. That way, you can copy and paste phrases into the electronic medical record. This works great for locum work or if you are traveling to different sites.
Keep your smart phrases up to date.
Ensure that your smart phrases are up to date with the latest evidence-based guidelines and protocols. Review them periodically to make sure they still accurately reflect current best practices. Then use these smart phrases in the hospital setting!
Use smart phrases to save time.
Keep track of how much time is saved by utilizing smart phrases! Utilizing smart phrases in a hospital setting will help nurse practitioners spend less time documenting so they can spend more time with their patients!
By incorporating these tips into your practice, you can use smart phrases effectively as a hospital nurse practitioner, ultimately improving patient care and streamlining your documentation process. Utilizing smart phrases in a hospital setting will help nurse practitioners spend less time documenting, create a better work-life balance, and overcome nurse practitioner burnout!
Check out The Nurse Practitioner Charting School’s Comprehensive List of Smart Phrases to help you jump start your charting success!
Erica D the NP is a family nurse practitioner and The Nurse Practitioner Charting Coach. Erica helps nurse practitioners STOP charting at home! Erica created The Nurse Practitioner Charting School to be the one stop for all documentation resources created specifically for nurse practitioners. Learn more at www.npchartingschool.com
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