8 Time-Saving Charting Tips for Nurses

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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’s a saying: “If you didn’t chart it, it didn’t happen.” 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’s difficult to balance in-depth charting while also trying to give your patients excellent care.

Surveys have shown nurses spend three of their 12 hours at work charting. That’s 25% of every shift and over nine hours per week. Nurses typically don’t 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.

8 Time-Saving Charting Tips for Nurses

As a nurse, you chart in many places. Here are a few changes you can make to decrease the time you spend charting so you’re done at shift change and can go home right away.

1. Use Templates

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!

For example, your plan for a patient you see this week with an upper respiratory infection probably isn’t 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’re done with minutes to spare.

2. Chart as You Go 

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!

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.

3. Chart Abnormals Immediately

If you don’t 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’ll know everything else was normal, and you can often click things like “all normal” which helps speed things along.

4. Use Automated Nurse Charting Features

Get to know the resources that are available to you. For example:

• Are there shortcuts you don’t know? Take a tutorial on your EHR system’s features.
• Use a speech-to-text dictation tool or AI function to save time on typing and minimize the risk of errors.
• Is there a way to select more elements faster, like clicking a whole row instead of each category?
• Can you save templates? Build a bank of common notes you can pull from frequently.
• Move away from paper notes. Every time you use a pen, that’s a keystroke you’ll need to enter later. EHR notes are already in the system (and they’re more HIPAA-compliant).
• Are there shortcuts you can learn from co-workers? Ask others how they save time.

Master these techniques and start applying them. They’re designed to save time and make your job easier.

5. Use Keyboard Shortcuts 

This tip might seem obvious, but make use of keyboard shortcuts like “cut” and “paste.” If you’re reusing parts of old notes, simply copy and modify them using these shortcuts. This saves time by eliminating the need to constantly click through different options, allowing you to work more efficiently. Quick commands (like Ctrl + F for “find”) can be a timesaver, too, and will become a habit with repeated use.

6. Delegate Simple Tasks

You don’t have to do all the charting yourself. Have your medical or nursing assistant chart things like vital signs, chief complaints, patient histories and intake and output. You can always go back and check that these notes were entered, but you don’t have to spend time doing every task or bit of charting yourself. 

7. Time Yourself 

Only allow yourself a certain amount of time for each element of charting. This trick is especially helpful when writing narrative notes. Tell yourself, “I’m only going to spend five minutes on this.” Set the timer and stick to it. Don’t sit there and stress out about perfecting the note past that time frame. 

8. Be Okay with Being Okay 

Your chart doesn’t need to be perfect. It needs to be accurate, and you must be sure to document any interventions you did or anything abnormal you found—but everything else does NOT need to be perfect. The next nurse or provider just needs to understand your plan and the patient’s status when in your care. They don’t need every little detail of your shift. Having A+ charts is unrealistic. Learn to be okay with being done, not being perfect.

Ready to Get Home on Time? 

The next time you’re charting a patient, try implementing one of these tips and gradually incorporate the rest. These strategies will save you valuable time each day, allowing you to focus more on providing quality care to your patients rather than stressing over perfect charting. Remember, done is better than perfect, and you deserve to finish your shift on time.

With all the demands of being a nurse, it’s important to stay focused. Check out our related article, How to Avoid Common Time Management Pitfalls in Nursing, for more tips. Unlock even more potential in your career by exploring the latest job openings posted by staffing partners on Vivian Health today.

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Editor’s Note: This post was originally published in August 2022 and updated in October 2024.