Tips for Charting Efficiently During Admissions and Discharges

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1 day ago
3 min read

Admissions and discharges are some of the most documentation-heavy times in a nurse’s shift. Between collecting history, completing assessments, entering orders, coordinating transitions, and documenting everything clearly, it’s no surprise that many nurses feel overwhelmed. And in busy med-surg or ICU environments, time is a luxury.

But it is possible to manage it all without sacrificing accuracy or staying an hour late, especially with some tried-and-true charting strategies.

Tips for Charting Efficiently During Admissions and Discharges

1. Front-Load Your Workflow with Core Assessments

Many seasoned nurses recommend conducting a quick “core” assessment at the beginning of your shift, especially during the morning medication pass. This includes checking neurological status, lung sounds, pain levels, peripheral edema, and any other critical assessments relevant to your floor (such as GI assessments for GI units).

Why? It allows you to start gathering information while completing tasks you already need to do (such as administering medication). You can then chart a brief version in real-time or take quick notes for detailed charting later.

That method builds a foundation for accurate, defensible documentation, without sacrificing your patient care rhythm.

2. Chart in the Room (Whenever Possible)

The closer your documentation is to the patient encounter, the more accurate—and efficient—it becomes. Charting immediately after (or even during) your assessment can save you hours on your shift.

Even if patients are chatty, most are understanding and accommodating. Try saying: “I’m going to do a little charting here in the corner, then we’ll get you comfortable.”

Charting at the bedside isn’t just faster—it also helps reduce forgotten details and keeps I&Os and assessments fresh in your mind.

3. Keep It Simple, Relevant, and Within Your EMR Flow

The best charting is accurate, but not excessive.

One major time sink? Redundant documentation. For example, if your EMR flow sheet already marks “clear breath sounds” as usual, there’s no need to type it again in your note.

Instead:

Chart by exception: If it’s normal, check the box and move on.
Use drop-down menus and templates efficiently.
Skip narrative notes unless something is abnormal or eventful (e.g., refusal of care, falls, adverse reactions).

Double and triple charting can not only waste time but also increase your legal risk if inconsistencies arise during audits or litigation.

4. Use Pended Notes and Micro-Moments

One clever trick? Start your admission or discharge note early and pend it. That way, you can edit as your shift evolves rather than waiting until the end of the day.

Another trick: Use micro-moments. While a patient takes meds, uses the bathroom, or answers a phone call, pull out your device or workstation and chart something.

5. Discharge First, Admit Second (When Possible)

If you’re managing both discharges and admissions, prioritize discharges first when appropriate. Discharge planning often has external deadlines (transport, family waiting, room turnovers). Completing those early helps prevent a logjam later.

Admissions, while time-intensive, can usually be staggered or supported by other team members once the patient arrives.

6. Avoid Post-Shift Edits

While editing throughout your shift is smart, going back the next day to chart what happened yesterday can be dangerous. Most EMRs timestamp every edit, and backdating or adding after shift ends could be used against you legally.

Stick to real-time or same-shift documentation. And if you forget something minor, consider whether it’s more legally sound to let it go than to raise a red flag.

7. Burnout Is Real and Efficiency Helps Fight It

Studies show that healthcare workers spend ~40% of their work time on documentation, more than on direct patient care (≈~28%) or coordination (≈~16%). If this time isn't used wisely, it can lead to errors, burnout, and a loss of valuable time with patients.

The current state of the EHR is frequently identified by physicians as the single most significant stressor in patient care, and nearly 75% of those with burnout symptoms cite the EHR as a source.

Apps like NurseMagic™ are HIPAA compliant and let you type or speak your situation, then generate a nursing note instantly. Notes can then be exported into your EMR with a simple copy-paste.

These small workflow changes matter. They’re about keeping you sane and preserving time for the reasons you became a nurse in the first place.

With the right tools and habits, you don’t have to choose between good documentation and good care. You can have both and still leave on time.