Top Tips and Tricks to Improve Your Nurse Charting

hello067308
11 minutes ago
3 min read

Nurses spend an average of 40% of their shift documenting care. It’s how you communicate with your team, protect your license, and ensure your patients receive the best care possible. But let’s be honest, charting can be time-consuming, mentally draining, and stressful, especially during high-acuity shifts. So how do you get better at it?

Here are practical tips and tricks to improve your nurse charting and save time without cutting corners.

Top Tips and Tricks to Improve Your Nurse Charting

1. Know Your Charting Format Inside and Out

Whether you're using SOAP, PIE, DAR, or Narrative, you should be comfortable with the format required at your facility. Don’t just wing it. Learn the structure and what’s expected in each section.

Knowing where to place specific patient information (e.g., subjective vs. objective data) speeds up documentation and reduces errors. According to a recent study, using a standardized format speeds up the documentation process and improves the notes' quality.

Pro tip: If your facility offers documentation training or cheat sheets, use them. If not, create your mini-guide based on the most frequent documentation patterns you see.

2. Chart in Real-Time (Whenever Possible)

It’s tempting to wait until the end of your shift to document everything, but that’s when mistakes happen. Details fade. Time stamps get messy. And worst of all, you risk forgetting critical events.

Charting in real time (or at least right after each patient interaction) protects you legally. It’s also easier on your brain. You don’t have to keep replaying events in your head while trying to manage the rest of your shift.

Pro tip: Use downtime wisely. Even 30 seconds while waiting for a pump to prime can be enough to jot down a quick note.

3. Use Objective, Specific Language

Avoid vague phrases like “patient doing well” or “vitals stable.” Those don’t mean much in a legal chart or to the next nurse taking over your shift.

Instead, use measurable, observable language:

✔️ “Patient ambulated 30 feet with a steady gait, no assistance.”
✔️ “Blood pressure 132/84 mmHg at 1400, denies dizziness.”

Objective, specific language reduces the chances of misinterpretation and increases the defensibility of your documentation.

Pro tip: Pretend your charting will be read in court because it might be.

4. Use Templates But Don’t Copy and Paste Blindly

EMRs often have templates or prefilled checkboxes to speed things up. Use them to your advantage, but be cautious. Copying and pasting previous notes can lead to outdated or inaccurate documentation.

Templates should guide your charting, not do the work for you.

Pro tip: Always double-check that what’s auto-filled reflects the current situation.

5. Start with Abnormal Findings

When time is tight, don’t start by documenting everything that's normal. Prioritize what’s wrong. This approach ensures that the most clinically significant info is captured first.

Once you’ve documented the abnormal findings, go back and fill in the routine stuff.

Pro tip: In emergencies or when pulled in 10 directions, this approach helps ensure your most critical documentation doesn’t get lost.

6. Keep a Running List of Must-Document Items

Each shift has recurring events you must chart: med administration, vital signs, patient refusals, falls, skin checks, pain reassessments, etc. Keeping a mental or physical checklist (even a sticky note on your badge) helps ensure nothing gets forgotten.

Pro tip: Cross items off throughout the shift to avoid an overwhelming backlog of tasks at the end of your day.

7. Ask Yourself: “Could Another Nurse Follow This?”

One of the simplest ways to audit your charting is to ask: “If someone new picked up this chart tomorrow, would they know what’s going on?”

If not, clarify:

Why a medication was held
Why the patient didn’t ambulate
What was done in response to a symptom

Clarity helps everyone: your team, your patient, and your license.

8. Use AI Tools to Lighten the Load

Documentation doesn’t have to be done alone. NurseMagic™ now allows you to speak or type patient scenarios and automatically generate professional notes in your facility’s preferred format.

This can significantly reduce the time you spend charting, helping you focus more on patient care and less on paperwork.

Final Thoughts

Charting doesn’t have to be the bane of your shift. With the right habits and tools, it can become just another seamless part of your workflow. Whether you’re just starting out or looking to level up your documentation game, these tips will help you write faster, chart smarter, and protect your practice.