Nurse practitioner charting template As The Nurse Practitioner Charting Coach, I will teach you how to chart as a new grad NP! I don’t know about you, but I did not feel prepared coming out of nurse practitioner school. Nurse Practitioners manage a broad range of health issues, emphasizing primary care and health promotion. However, there are those who don’t follow the guidelines strictly. May 19, 2022 路 Different intake and progress notes and follow-ups in mental health, the importance of patient documentation in psych. The prescriptive authority of a Certified Nurse Practitioner, Clinical Nurse Specialist or Certified Nurse Midwife shall not exceed the prescriptive authority of the collaborating physician or podiatrist. It is designed to support consistent and complete documentation, especially for training or reference. Whether you are a nurse practitioner student, new graduate, or experienced APRN, there are helpful tips for all specialties of nurse practitioners. There are ways to upload templates into electronic medical records with automatic functions that further saves time. Sep 7, 2024 路 Nursing faculty, mentors, and fellowship leaders in nurse practitioner (NP) programs teach documentation of objective patient examination findings and the medical decision-making process, often by using standard template-based charting in the electronic medical record (EMR). * Develop and Cardiac Rhythm Assessment by ECG Sinus rhythm: Normal sinus rhythm (NSR) [P wave before every QRS, P-R interval < 0. This SOAP note template for nurse practitioners includes sample instructions under each section to guide what type of information should be entered for subjective data, objective observations, assessment, and plan. Download, Fill In And Print Nursing Chart Review Template Pdf Online Here For Free. Each protocol should be Mar 18, 2024 路 We collected Nurse Practitioner Collaborative Agreement Templates across all 50 states. By implementing small, attainable changes, nurse practitioners can actually achieve the Clear and accurate nursing notes are essential for monitoring patient progress and facilitating communication among healthcare professionals. Improving Medical Documentation NP-Notes is the cure for documentation burnout. Now is the time to STOP charting at home and spend more time with your family! Get access to over 125 smart/dot phrases! The Comprehensive List of Smart Phrases for Nurse Practitioners! Only $37!! Save time, reduce errors, and streamline your work-flow with expertly crafted mental health templates and cheat sheets for compassionate providers just like you. net. Learn how structured documentation can enhance patient care and streamline your practice. Luckily, APRNs can implement tips to help them save time charting the HPI. Many providers complain that their documentation systems are clunky and time-consuming, designed more for hospital administrators. B. But the challenge comes where you have a hard time balancing attending to your patient’s needs and charting to ensure every detail you’re passing across to other health practitioners is accurate. In this article, we will discuss one type of nursing notes, SOAP nursing Enhance Your Healthcare Documentation with Professional Nurse Templates by Template. Download PDF, copy, customize. As The Nurse Practitioner Charting Coach, Erica helps overwhelmed NPs improve their charting, get their time back, and finally STOP charting at home! Using a nursing note template ensures that essential information is captured and recorded consistently, making it easier for nurses and other healthcare professionals to track patient progress and respond to patient condition changes. Dec 4, 2024 路 Studying complex disease processes can feel overwhelming, but these free printable Nursing Student Disease Templates are designed to help make it a little easier. Is nurse charting the bane of your existence? See different examples of nursing notes and discover tips to improve your documentation skills. Smart phrases (also called dot phrases) are a block/combination of frequently used words that can be easily pasted into the chart note. Templates improve billing and increase compliance with documentation of core measures. The most important step to improve charting as a nurse practitioner is to commit to putting in the effort to do so. Erica shares her own journey from burned out RN to efficient NP, and how her passion for helping others overcome charting challenges led her to start The Nurse Practitioner Charting School. Our interactive, diagnosis specific note templates make it possible to document (almost) painfree. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. As a nurse, your primary task will be that of looking after your patients and charting. I agree the physical exam performed was appropriate for the symptoms The 411 on Documenting a HEENT Exam If you’re a nurse practitioner new grad, documenting a patient encounter can be a bit of a struggle. However, I have seen a lot of nurse practitioners spend too much time on this section. Highfile’s templates align with standard nursing documentation practices for recording observations, treatments, and patient responses. In such a case, they may need This charting templates tutorial is a game-changer for nurse practitioners! 馃帀 You’ll learn how to create custom charting templates, personalize SOAP note content, use Magic Edit, and Charting and coding content for ER providers. C- Commit to making a change. Pre-charting, or preparing the chart before seeing the patient, is a helpful time-saving tip a nurse practitioner can easily implement! Nov 14, 2025 路 Here’s a refresher on what and how to chart as a nurse, as well as tips for avoiding some of the most common documentation mistakes. Why is this nursing documentation template useful for healthcare professionals? Writing nursing notes is crucial for documenting patient reports, including changes in vital signs, and ensuring patient education. Whether you are a student, resident, or experienced practitioner, these examples will help you refine your note-writing skills and ensure comprehensive, professional documentation for various psychiatric scenarios. A SOAP note is a structured form of documenting and assessing client or patient care. Many APRNs are staying late at the office or bringing Pre-charting, or preparing the chart before seeing the patient, is a helpful time-saving tip a nurse practitioner can easily implement! Nov 14, 2025 路 Here’s a refresher on what and how to chart as a nurse, as well as tips for avoiding some of the most common documentation mistakes. The Nurse Practitioner Charting School shares these examples of a SOAP note plus 7 tips to help nurse practitioners chart! Erica helps nurse practitioners STOP charting at home! Erica created The Nurse Practitioner Charting School to be the one stop for all documentation resources created specifically for nurse practitioners. Practicing NPs need the capabilities to be able to record precise examination findings. In such a case, they may need Nurse practitioners, prioritize care over clerical tasks Nurse practitioners leverage PatientNotes for AI-driven documentation that is secure, efficient, and detailed, allowing more time to be spent on patient care rather than paperwork. With this template, you can easily: Staff who might be involved in wound care and responsible for following wound care policies and procedures include: Registered Nurses (RN), Nurse Practitioners (NP), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), Physicians (MD/DO), Physician Assistants (PA), and External Wound Care Consultants. It does help me chart more quickly, but customizing my own templates has also helped me reflect on the diagnostic process with various presentations. How will Smart Phrases for Nurse Practitioners save me time charting? Don’t wait until you are beyond burned-out to change your charting. method to improve charting as a nurse practitioner. Unique challenges exist using Streamline patient visits with this physical exam template cheat sheet. May 14, 2025 路 SOAP Note Template This SOAP note template was created by a nurse practitioner to capture detailed SOAP notes, particularly for complex cases or when multiple issues are raised during a single visit. H. Use these collaborative agreement templates to create your own. net Bring your healthcare documentation to life with expertly crafted pre-designedNurse Templates in Microsoft Word by Template. With sections for pathophysiology, clinical manifestations, lab results, interventions, and more, these templates offer a clear, organized way to map out everything you need to know. R. Explore 25 practical dot phrase templates designed to simplify medical documentation and enhance communication in healthcare settings. It is not the intent of the Board to provide this protocol so that a physician simply copies the material contained herein nor to suggest that the arrangement discussed in this example is the ideal arrangement. I created The Time Management and Charting Tips Course to teach nurse practitioners how to chart accurately and efficiently, so you can STOP charting at home. Check out our nurse practitioner charting template selection for the very best in unique or custom, handmade pieces from our templates shops. Oct 21, 2025 路 These free printable nurse report sheets or nurse brain sheets are a practical tool designed to keep all the important details for your nursing shfit. PMHNP Documentation Templates We also offer a PMHNP Documentation Templates Bundle to create streamlined, expert psychiatric evaluation templates and follow up note templates for new and experienced psych–and family–NPs who want more clarity and efficiency in documentation. ” And the work never seems to end. Ensure clear and organized records for quality patient care. There are many types of documentation nurses and other healthcare professionals use. Unique challenges exist using Oct 1, 2025 路 Instead, I’ve adopted the use of charting templates, commonly referred to as macros, using the SOAP note format. Freetext procedure notes, MDM notes, Physical Exam notes, etc Updated for the new 2023 CMS guidelines A neuro exam is one of the most complex to master when it comes to assessment and documentation. Triage Forms Profession Specific Resources Profession Specific Resources Nurse Practitioners Oral Health Physicians Professional Practice and Development What is a complete review of systems? According to the 1995 guidelines for medical documentation, there are 10 systems that constitute a complete ROS needed for Level 5 visits. When customizing my templates, I ask myself: Is nurse charting the bane of your existence? See different examples of nursing notes and discover tips to improve your documentation skills. Seems that nurse practitioners were just designed to do what doctors do but for a fraction of the price. Proper documentation supports continuity of care, legal requirements, communication among healthcare teams, and Save time charting with customizable NP charting templates! 馃┖ Nurse practitioners, streamline your SOAP notes and improve charting time management using proven EHR templates. Guide to the Comprehensive Adult H&P Write鈥怳p (Adapted from D Bynum MD, C Colford MD, D McNeely MD, University of North Carolina at Chapel Hill, North Carolina) Sep 8, 2021 路 All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Sep 23, 2024 路 Head to Toe Assessment Checklist Template Get an example head-to-toe assessment template today! Perfect for a nursing student or a practicing nurse in the field. Available in Word, PDF and Google Docs formats it can be used in clinical Psychiatric nursing notes: Essential documentation capturing patients' mental health assessment, interventions, and treatment progress. Most schools emphasize on learning the disease process, assessment, diagnosis, prescribing, and how to Aug 1, 2025 路 Nurses: Nurses are often responsible for conducting initial assessments of patients, and a Head-to-Toe Assessment is a crucial part of this process. The Nurse Practitioner Charting School will teach nurse practitioners about time management, time-saving charting tips, and so much more! No matter if you are a nurse practitioner student, new grad, or experienced advanced practice registered nurse (APRN), The Nurse Practitioner Charting School can help you chart accurately and efficiently so you can STOP charting at home! Download, Fill In And Print Nursing Chart Review Template Pdf Online Here For Free. Streamline your NP documentation with our comprehensive nurse practitioner SOAP note template. For psychiatrists, nurse practitioners, nurses, physician assistants, residents, and students. Here are the SOAP note templates that you can print and use for free. Apr 3, 2024 路 I’ve developed several SOAP charting templates with checklists that were especially helpful as a new graduate, and still help me to this day. Learn how to document a neurological exam as an NP. Includes SOAP note templates, examples & step-by-step instructions for clinicians. Even if that is not your specialty as a Psychiatric Mental Health Care Nurse Practitioner (PMHC NP), you will see see it in every setting. Each printable is free to download and formatted as an easy-to-print PDF. Mental Health Mental health is a hugely important factor in SOAP notes are a type of documentation which, when used, help generate an organized and standard method for documenting any patient data. STUDENT(printed)__________________________________________________Date_________Client initials ________Room Number_______NANDA DX Oct 21, 2025 路 Nurse Practitioner | NOT Another Note - charting templates for primary care | works with ANY EHR | Stop charting at night and on weekends! Free SOAP note templates for all healthcare specialties. A collection of FREE printables for nurses and nursing students offering shift planners, patient care logs, and medical record templates. Nursing Chart Review Template Is Often Used In Nursing Notes Template, Patient Assessment Form And Patient Care. PMHNP documentation and evaluation templates, the Mental Disorders Crash Course, and other free resources. With this template, you can easily: Nov 13, 2024 路 In this episode, Anna sits down with Erica D, the NP Charting Coach, who specializes in helping nurse practitioners improve their charting skills. When you review all of the systems with patients, you need to use documentation like a review of systems checklist. Erica is a family nurse practitioner, wife, mom, and creator of The Nurse Practitioner Charting School. A. When I started out as a brand new primary care nurse practitioner, I became completely overwhelmed. This template includes all essential elements for comprehensive evaluations, chronic care management, and acute care visits. Especially when it came to charting. 5 days ago 路 Reusable clinical documentation templates nurse practitioner use streamline patient records by providing standardized, editable forms for efficient data entry. You need to present your patient in a manner such that other providers can glance at the chart and pick up where you left off. . In LTC/SNF settings, many of your visits are routine or follow-ups, such as: 30-day, 60-day, 90-day recertifications Annual wellness Utilize the C. These notes provide a comprehensive record of a patient's treatment, including observations, data, treatment plans, and progress updates. Sep 26, 2025 路 Download free Clinical SOAP Note Templates for easy documentation of patient data. Many nurse practitioners add too much information, creating note bloat. Dec 2, 2023 路 Nurse practitioners spend a significant portion of their time charting, but by using smart phrases, setting patient boundaries, creating problem-focused notes, and allowing time for recharge, they can improve their efficiency and work-life balance. Whether you’re a psychiatric nurse practitioner (PMHNP) or psychiatric APRN, ICANotes is built to streamline your documentation. Ready to STOP charting at home? The Nurse Practitioner Charting School will teach nurse practitioners about time management, time-saving charting tips, and so much more! Each example provides detailed insights into the Subjective, Objective, Assessment, and Plan components of SOAP notes, offering valuable templates for nurse practitioners to improve their patient care documentation. SOAP note format Supports structured and organized documentation, including the EHR Guides nurses to use clinical reasoning to assess, diagnose, and treat a resident based on available information If you’re a nurse practitioner who could use a documentation brush up, check out this quick guide to documenting a cardiovascular exam. Psychiatry Progress Note Templates to Streamline your Practice. Aug 13, 2024 路 That's why we've taken the time to collate some examples and SOAP note templates, which we think will help you write more detailed and concise SOAP notes. Any type of health professionals can use a SOAP note template – nurse practitioners, nurses, counselors, physicians, and of course, doctors. Many APRNs are staying late at the office or bringing Delve into the intricacies of psychiatry progress notes, from effective writing techniques to the advantages of using templates. Mar 24, 2025 路 This nursing notes template was designed by a nurse practitioner to capture detailed patient encounters. Aug 1, 2025 路 Download a SOAP Notes for Nursing Template to streamline nursing documentation. Charting Tips for LTC/SNF Nurse Practitioners Here are a few specific charting tips for LTC/SNF nurse practitioners! Tip #1: Create Custom Templates One of the easiest and most effective ways to streamline your documentation is by using custom charting templates. Nursing notes are the way healthcare providers communicate and promote continuity of care. Utilize the C. Utilize these 4 Charting Tips for Nurse Practitioners to document in real-time, stay on schedule, and STOP charting at home! Mar 24, 2025 路 A nursing notes template is a tool commonly used to streamline the production of nursing notes. Ideal for professionals within the healthcare industry, these templates allow you to create thorough and professional documentation swiftly, even without extensive design The HPI is the information that the patient tells the nurse practitioner and is an important part of the chart note. Nurse practitioner charting in psychiatry demands more than generic templates. Here are some nursing note templates and examples in editable PDF, Google Docs, and Word to get you started. Is this you? So many nurse practitioners struggle with “note bloat” and over documenting! This causes nurse practitioners to constantly run behind during the work day. Apr 15, 2025 路 Use this SOAP (Issues) for Nurse Practitioners template for Nurse Practitioner with Heidi AI to create a professional document for your patients. Dec 27, 2024 路 How to Write Psychiatry Notes with Examples and Templates Writing effective psychiatric notes is essential for high-quality mental health care. In this sample chart review, CQI, clinical concerns and other issues are reviewed and documented. The Nurse Practitioner Charting School offers several charting tips, time management hacks, info on billing & coding, and legal issues with charting. PDF and WORD formats. Oct 24, 2025 路 Discover 10 essential nurse practitioner charting templates to enhance efficiency in patient care. Which causes a lack of work-life balance and puts NPs at a significant risk factor for nurse practitioner burnout. Physician assistants: Physician assistants often work alongside doctors and can perform many of the same duties, including conducting patient assessments. Which causes NPs to stay late at the office or bring charting home. Ideal for nurse practitioners seeking organized documentation. Smart phrases are Nurse practitioners, prioritize care over clerical tasks Nurse practitioners leverage PatientNotes for AI-driven documentation that is secure, efficient, and detailed, allowing more time to be spent on patient care rather than paperwork. A family nurse practitioner and creator of The Nurse Practitioner Charting School. Oct 17, 2025 路 Oct 17, 2025-Learn how to properly document musculoskeletal assessments with our comprehensive guide. Mar 28, 2021 路 Health professionals must have an accurate record of their patients. One type of documentation is a Dec 11, 2024 路 What Nurse Practitioners Do While historically the Nurse Practitioner role began in rural primary care, Nurse Practitioners practice in many settings such as specialty practices, hospitals, managed care, long-term care, and public health. Aug 1, 2025 路 Access a Psych Nursing Assessment Cheat Sheet to efficiently evaluate mental health patients, streamlining the process for effective and informed care. By including a pre-defined structure and prompts, a well-designed nursing notes template reduces the cognitive load involved in documentation and ensures compliance with institutional and regulatory requirements. 5 Perfect Nursing Progress Notes Examples + How to Write Written By: Darby Faubion RN, BSN, MBA If you are a nurse, you know one of the most important parts of our jobs is to document about our patient’s status, the care they receive, and their response to any treatments. This program provides the EXACT charting and time management tips to help nurse practitioners STOP charting at home in the next 90 days! A family nurse practitioner and creator of The Nurse Practitioner Charting School. With this template, you can easily: Utilizing smart phrases as a hospital based nurse practitioner can help NPs save sooooo much time charting! Smart phrases are pre-written phrases or sentences that can be quickly inserted into your electronic medical record (EMR) system. It is important for nurse practitioners to reflect on how their current charting burnout is affecting their life. A Medical Chart Review Form is used by healthcare professionals and medical facilities to assess and document the medical records of patients. T. Aug 1, 2025 路 Streamline patient assessments with our 14-Point Review of Systems Template as a valuable screening tool for early detection and diagnosis of various health conditions. Focus on this charting tip for NPs. Mental health, nursing, physical therapy, and more. Learn how SOAP May 12, 2021 路 Psych. Aug 22, 2022 路 While the nurse practitioner can perform the face-to-face visit, it is up to the hospice medical director to review the documentation and certify the patient still meets hospice criteria. How important is accuracy when documenting the chief complaint in an HPI? * Muscle tone and strength * Casts * Notify the Physician of abnormal findings of concern * Implement the nursing process * Analyze the data tify the appropriate nursing diagnoses. Aug 1, 2025 路 Typically, any healthcare provider involved in patient assessment can complete an HPI, including physicians, nurse practitioners, physician assistants, and sometimes registered nurses, particularly in emergency department settings where detailed patient histories are crucial. Learn how to write SOAP notes with these examples. Download the Psychiatric Templates bundle for streamlined, pmhnp documentation templates for more clarity and efficiency in mental health documentation for stress-free psych NPs. Choose from thousands of templates geared towards Family Medicine, Pediatric, Emergency Medicine, Urgent Care, Inpatient, and other specialty settings. How important is accuracy when documenting the chief complaint in an HPI? Oct 4, 2025 路 The Nursing Process highlights the best practices for composing a nurse practitioner SOAP note template, emphasizing the importance of clarity, conciseness, and accuracy in documentation. 5 Perfect Nursing SOAP Note Examples + How to Write Written By: Darby Faubion RN, BSN, MBA One of the most important parts of a nurse’s job is documentation, and there are several types of nurses' notes used in nursing care today. Our EHR combines psychiatric-specific note templates, medication management, and billing so every mental health nurse practitioner can save time while staying compliant. SAMPLE PROTOCOL The following is a sample protocol intended to provide physicians an idea of what the Board expects in the layout and content of a protocol. This worksheet and the accompanying guidelines contain the items of assessment used for the documentation review portion of the NP peer review. There are so many ways nurse practitioners can improve their charting! Make it a point to focus on one thing at a time. This is an example of what a NP/PA-Physician collaborator meeting may include. We have samples of chart review indicators. These tools are perfect for nurses looking to stay organized during busy shifts. These templates are designed for detailed record-keeping and easy documentation. Whether you're preparing for exams, working on Aug 1, 2025 路 What is a Nurse Practitioner Collaborative Agreement Template? A nurse practitioner collaborative agreement is a formal, written agreement between a nurse practitioner (NP) and a collaborating physician outlining each party's obligations, roles, and duties when providing health care services to patients. The nurse has to know everything that is going on with the patient at any given time. Practitioners can use this SOAP note template to collect and measure relevant medical information and easily create actionable health plans for clients. The indicators are based on the Entry Level Competencies for Nurse Practitioners in Canada, the Scope of Practice for Nurse Practitioners and other applicable BCCNM Standards of Practice (Scope of Practice for NPs, Professional Standards and Practice Please see below for Sample Nurse Practitioner/PA-Physician Collaborator Review Meeting. There is so much information to learn in nurse practitioner school. S. The cardiovascular system consists of more than just the heart. Sep 12, 2024 路 Use this SOAP Detailed template for Nurse Practitioner with Heidi AI to create a professional document for your patients. Learning how to write a great psych note as a NP will enhance your services, make a more accurate note in the patient’s chart and help you offer great options that could be lifesaving. For example, there are findings like jugular venous distention and peripheral pulses to note. She’s considering going back to bedside sometimes. Nov 13, 2024 路 In this episode, Anna sits down with Erica D, the NP Charting Coach, who specializes in helping nurse practitioners improve their charting skills. So it’s like 10+ hours a day actually at her office and then God knows how long charting at home. DOCUMENTATION OF THE NOTE NURSING DOCUMENTATION The Hospice Nurse is responsible for management of the patient as a whole. It’s ideal for documenting complex cases, including sections for subjective and objective findings, assessments, and treatment plans. May 12, 2025 路 FPM Toolbox Download more than 200 free practice improvement tools -- from coding cheat sheets to encounter forms to Medicare annual wellness visit resources. Designed by Nurse Practitioners with over 10 years of clinical experience, these 14 templates are crafted to help you efficiently and accurately document patient history, review of systems (ROS), and physical exam findings for each body system. 20, rate is between 60 to 100] 5 days ago 路 Reusable clinical documentation templates nurse practitioner use streamline patient records by providing standardized, editable forms for efficient data entry. Save 30 minutes per note. SOAP note example for nurses or nurse practitioners Subjective John reports feeling tired and struggling to get out of bed in the morning. Psychiatric nursing notes: Essential documentation capturing patients' mental health assessment, interventions, and treatment progress. ici fzohh jhkuu igd jhldy vjm vtgx afpw tmqn dtvroc icihc surot pccbi eqtv pznlpc