{"id":5270,"date":"2024-10-17T08:25:07","date_gmt":"2024-10-17T08:25:07","guid":{"rendered":"https:\/\/www.vivian.com\/community\/?p=5270"},"modified":"2024-10-17T14:35:33","modified_gmt":"2024-10-17T14:35:33","slug":"8-nurse-charting-tips","status":"publish","type":"post","link":"https:\/\/www.vivian.com\/community\/career-resources\/8-nurse-charting-tips\/","title":{"rendered":"8 Time-Saving Charting Tips for Nurses"},"content":{"rendered":"

Since the introduction of the electronic health record (EHR) and stricter HIPAA regulations, nurses spend a lot more of their time charting. In healthcare, there\u2019s a saying: \u201cIf you didn\u2019t chart it, it didn\u2019t happen.\u201d Nurses are under a lot of pressure to chart their work thoroughly for accountability and precise record-keeping. However, many nurses will agree that it\u2019s difficult to balance in-depth charting while also<\/span> trying to give your patients excellent care.<\/span><\/p>\n

Surveys have shown nurses spend three of their 12 hours at work charting.<\/span> That’s 25% of every shift and over nine hours per week. Nurses typically don\u2019t have three hours to spend on the computer each shift. To make your time more efficient, try integrating these tips and tricks to help you finish your charting and get home on time.<\/span><\/p>\n

8 Time-Saving Charting Tips for Nurses<\/strong><\/h3>\n

As a nurse, you chart in many places<\/span>.<\/span><\/i> Here are a few changes you can make to decrease the time you spend charting so you\u2019re done at shift change and can go\u00a0home right away.<\/span><\/p>\n

1. Use Templates<\/strong><\/h4>\n

Templates are lifesavers for things like free-text notes. You can create templates for certain complaints, exams and patient plans. This practice prevents you from having to type the same thing over again. Instead, you use your premade template and insert the relevant patient information. It saves a ton of time!<\/span><\/p>\n

For example, your plan for a patient you see this week with an upper respiratory infection probably isn\u2019t different from the one you saw last week. If you have a saved template, you can copy and paste details into your note, and you\u2019re done with minutes to spare.<\/span><\/p>\n

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2. Chart as You Go\u00a0<\/strong><\/h4>\n

Some nurses prefer to complete all their charting at the end of their shift; however, this approach has been shown to be ineffective for time management. You never know how much time you’ll have at the end of a shift or whether an unexpected event will require you to stay late to finish charting. Instead, chart as you go!<\/p>\n

Most healthcare facilities now provide computers in patient rooms, whether in hospital rooms or exam rooms in outpatient clinics. As you interact with your patient, chart in real-time. Document your assessments, plans and any other necessary information on the spot. This way, when you move on to the next patient, your charting is already complete, freeing you from having to catch up or rush through notes later.<\/p>\n

3. Chart Abnormals Immediately<\/strong><\/h4>\n

If you don\u2019t have time to chart your entire assessment in the room with a patient, just chart the abnormals from exams. When you have time to catch up, you\u2019ll know everything else was normal, and you can often click things like \u201call normal\u201d which helps speed things along.<\/span><\/p>\n

4. Use Automated Nurse Charting Features<\/strong><\/h4>\n

Get to know the resources that are available to you. For example:<\/span><\/p>\n