Tips for Charting When You’re in a Rush

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2 days ago
3 min read

If you’re a nurse, you’ve been there—juggling multiple patients, fielding questions from family members, and racing against the clock to finish documentation before your shift ends. The good news? With a few practical strategies, you can document thoroughly and accurately—even when time isn’t on your side.

Tips for Charting When You’re in a Rush

1. Use a Standardized Format

Using a consistent note structure like SOAP (Subjective, Objective, Assessment, Plan) or PIE (Problem, Intervention, Evaluation) makes it easier to focus on what needs to be included. These formats guide your thinking and help you quickly organize key details, so you’re not starting from scratch every time.

According to a recent study, using a standardized format speeds up the documentation process and improves the notes' quality. This study highlights the critical role that structured documentation plays in enhancing patient outcomes and minimizing clinical errors.

2. Document in Real Time When Possible

The longer you wait to document, the more details you’ll forget. Whenever possible, jot down or voice-record your observations right after they happen—especially vital signs, pain levels, or changes in status. Even brief notes help you remember specifics when you’re able to complete the chart later.

Real-time documentation also improves accuracy and protects you if an issue arises. If time is tight, start with key interventions and outcomes. You can always fill in additional context during a calmer moment.

3. Use Templates or AI Tools Wisely

Pre-built templates and auto-text options within your EMR can speed up documentation—just be careful not to over-rely on them or copy forward outdated information. Tools like NurseMagic™ can also help generate high-quality, personalized notes based on voice input or keywords, saving precious time while keeping documentation professional.

Nurses spend, on average, about 40% of their shift performing documentation tasks. That’s hours every day. Tools that streamline this process not only reduce time spent charting but also help prevent burnout.

4. Focus on What’s Clinically Relevant

When time is limited, zero in on the information that supports clinical decisions, care coordination, and legal protection. This includes:

Vital signs and notable changes
Interventions performed
Patient response
Communication with providers or family

Leave out redundant or nonessential info. Charting is about clarity, not volume.

5. Keep a Running List

If you’re interrupted while documenting—which is often—keep a brief running list or voice memo on your phone (if allowed by policy) with key points to document later. Jot down initials, time, what you did, and how the patient responded. Even shorthand reminders can save you time when you finally sit down to chart.

6. Don’t Skip the Narrative When It Matters

Even when using checkboxes or templates, don’t skip a brief narrative when something unusual happens. A short paragraph describing a patient’s agitation, refusal of medication, or unexpected side effect can make a big difference during handoff or review.

Narratives are especially useful for:

Behavioral incidents
Family concerns
Patient refusals
Complex pain episodes

7. Stay Calm and Focused

It’s tempting to rush through charting when you’re behind, but sloppy documentation can cost more time in the long run. Take a breath, find a quiet spot (even if it’s just for a few minutes), and focus on one patient at a time. Accuracy matters more than speed.

Try grouping similar tasks—for example, charting on all wound care at once—so you stay in the same mental workflow.