You love your job as a travel nurse, but sometimes the stress of learning each new facility’s rules, systems, and programs leaves you anxious before the start of your contract.
Although it’s normal to have some nerves before your first big day, we want to alleviate as many of those nerves as possible. That’s why we’ve created this travel nurse charting tips guide to help you stay sharp and reliable at each new assignment.
Here you will learn:
- How to best prepare for the different electronic health record charting systems
- Extra charting tips to keep in your back pocket to ensure a successful charting experience
- And more
Table of Contents
- 3 Travel Nurse Charting Tips: Be Prepared by Getting to Know the Electronic Health Record (EHR) Charting Systems
- 7 Additional Charting Tips for Travel Nurses To Ensure a Smooth Shift
- Whether You’re Searching for Long-Term or Short-Term Travel Nursing Assignments, Trusted Nurse Staffing Has an Opportunity for You
3 Travel Nurse Charting Tips: Be Prepared by Getting to Know the Electronic Health Record (EHR) Charting Systems
If you’re a nurse working at a single hospital or facility, you learn one charting system and use it indefinitely — until you get a new position that uses a new system or your facility switches.
But if you’re a travel nurse, this isn’t the case.
Similar to medical onboarding processes, where every facility might have different rules and expectations, electronic health record charting systems are also different across facilities.
To best prepare before your first day at a new facility or location, become familiar with the most popular EHR systems. By having an idea of how each of them works, you’ll not only look prepared, but you’ll also be more efficient on the job.
Are you a nurse interested in travel assignments? Travel nursing could be for you! Trusted Nurse Staffing will help you:
- Find contracts that meet your needs
- Secure necessary training; and
- Provide support in your position
Contact us today to get started.
#1: Research Charting Systems
Familiarizing yourself with a handful of different charting systems can help you slide into your new travel nurse position a bit smoother.
You’ll likely receive a quick training on the EHR charting system used at each facility you work with, but having an idea of how the most popular charting systems work beforehand can be helpful before your first shift. If training isn’t offered, ask what your options are to learn a bit more about a charting system you’re unfamiliar with.
Below is a list of the ten most common EHR charting systems to familiarize yourself with:
- Epic Systems
- Netsmart Technologies
- Harris Healthcare
- Indian Health Service
#2: Find Parallels Between Charting Systems
Although there are many different charting systems, there are parallels between them that can help you become familiar a bit easier.
Try to remember the similarities in the systems by using idioms or acronyms to help you get through charting more quickly.
#3: Learn Keyboard Shortcuts
Keyboard shortcuts can save you so much time when it comes to charting.
Whether you’re attempting to quickly chart between seeing patients or you’ve saved it until the end of the day and are trying to get home, knowing common keyboard shortcuts used throughout EHR charting systems will prove helpful.
7 Additional Nurse Charting Tips for Travel Nurses To Ensure a Smooth Shift
Once you’ve got the hang of the various EHR charting systems, charting should be pretty simple, right?
Here are seven additional charting tips for nurses you’ll want to keep in mind.
#1: Check Out the Facility’s Charting Techniques Before Shift Change
As you’ve moved through various travel nurse assignments, you’ve begun to notice that most facilities are using the same one or two charting systems. Even though you’re now familiar with the most common EHR systems, you’re probably unfamiliar with how a specific facility likes to chart.
Maybe they have a certain technique? They might prefer things to be done one way or another.
Before you begin charting, take a minute to review the previous shift’s charts to get a clear idea of:
- The technique the facility uses
- What they expect; and
- What you should be doing
If things are unclear, don’t be afraid to ask a staff member for help, so you can best learn the facility’s preferences.
#2: Understand & Follow Your Facility’s Charting Procedures
You’ve taken the time to review the facility’s charting techniques, but now you should also spend time learning and understanding their charting procedures.
Does the facility require certain things while charting? Do you have to chart in a specific area, or can you chart on your nursing cart in the hall? What other system procedures might the facility have?
#3: Chart in Real-Time
Whenever possible, most facilities prefer that you chart in real-time. What does this mean?
Although you shouldn’t chart before you have completed the task and have all the necessary information, you should chart as much as you can as soon as you can — to an extent.
Facilities understand emergencies happen, circumstances change, and you’re a busy nurse, but the longer you wait to chart, the more likely you are to have charting mistakes.
Pro-tip: Keep a small piece of paper in your pocket and quickly jot patient info (using the patient’s room number instead of name for HIPAA purposes) as you gather it. This makes transferring information to your chart when you’ve got the time easier and allows for fewer errors.
#4: Chart for Others, Not Only for Yourself
Okay, you don’t actually want to do other nurses’ charting.
But when doing your own charting, keep in mind the nurse coming on shift after you and taking over your patient. You probably knew what you meant by the shorthand you jotted down, but the next nurse who is reading your charts and resuming care for your patient might not.
Depending on which state your current travel nurse contract is in, you might have three or four patients — or you might have six or seven. The nurse-to-patient ratio varies across states, so ensure your charts are accurate before your shift ends.
Consider these questions:
- Are your notes clear?
- Are you sure the information matches the correct patient?
- Did you leave out anything important?
Remember, patient care is your top priority, so by having clear and precise charts, you’re setting up your patients, the follow-on nurses, and the doctors for success.
#5: Ask Questions
This one might seem obvious, but sometimes it’s hard to come out of your shell when you’re the new face on the facility floor during travel nursing.
If you’re unsure about how a specific EHR charting system works at your new facility, ask someone who has been working there and using it for a while. They’ll probably be more than happy to guide you through their system.
#6: Take Notes as You Go — As Long as They’re HIPAA-Compliant
As long as you’re staying within HIPAA compliance, take notes on scrap paper you keep in your pocket as you visit patients throughout the day.
If you don’t have immediate access to a computer, old-fashioned paper and pen can help you remember the details. You can also write these notes in a way that you’ll understand them (like using your own shorthand) which can make transferring over to the EHR charting system easier.
To avoid any HIPAA issues, it’s best to shred these notes before you leave the facility at the end of your shift.
#7: Remember to Stay Objective
Despite how you might personally feel towards a patient — whether they’ve been rude, reminded you of someone you dislike, have done something you don’t agree with or believe in, etc. — your charting should never be subjective.
Ensure that your EHR charts are:
- Factual; and
The nurses on the next shift should be able to read your chart notes and understand exactly what is going on with your patients.
Whether You’re Searching for Long-Term or Short-Term Travel Nursing Assignments, Trusted Nurse Staffing Has an Opportunity for You
Learning and understanding the many popular electronic health record charting systems used throughout facilities today shouldn’t be a deterrent to becoming a travel nurse.
Our nursing charting tips can help you feel more comfortable starting at a new facility.
Maybe the stress of finding reliable travel nurse contracts is what’s holding you back from your travel nursing career.
Don’t let that stop you, either!
Trusted Nurse Staffing can help you find the right travel nurse contract that fulfills what you’re looking for.
Whether that is a …
- Local assignment
- Travel assignment
- Permanent placement
- Temporary to permanent placement; or
- Per diem assignment
… our agents have got you covered. We were even recognized as one of the leading national healthcare staffing companies in 2022.
Let our skills and expertise find you your next travel nurse assignment. Contact us today!