There was a season in my career when I dreaded opening the EMR. I felt like I spent more time clicking boxes than caring for patients. I left late, came home exhausted, and still worried I’d missed something.
That’s when I started experimenting with AI—not as a shortcut, but as a support tool.
Here’s the simple workflow that helped me cut my documentation time almost in half.
Step 1 – Capture rough notes in real time
Instead of trying to write perfect sentences during the shift, I switched to quick bullets:
- “0830 – post-op day 1, up to chair, pain 6/10…”
- “Wound: serosanguinous, no odor, dressing intact…”
The goal: capture facts now, polish later.
Step 2 – Feed the bullets into AI after the shift
At the end of the shift (or during a quiet moment), I pasted my bullets into an AI tool and said:
“Please turn this into a professional nursing note using complete sentences and objective language. Do not add any new information.”
Within seconds, I had a clean draft.
Step 3 – Edit with my clinical brain
I read the draft carefully:
- Was anything inaccurate?
- Did AI accidentally change a detail?
- Did the wording match my unit’s norms?
If needed, I tweaked phrases or deleted anything that didn’t feel right. I stayed in charge.
Step 4 – Reuse and refine prompts
After a few shifts, I saved the prompts that worked best:
- Med-surg note prompt
- Wound note prompt
- Hospice visit note prompt
Soon, I had my own mini prompt library, and the process got even faster.
What changed for me
- I spent less time fighting the cursor and more time actually thinking.
- I left on time more often.
- My notes were clearer and more consistent.
- I felt less mentally drained by the end of the week.
Conclusion & encouragement
If documentation is a major source of stress for you, consider starting with one small change:
Use AI as your documentation assistant for one patient, one day.
Track how it feels, how much time you save, and how clear your notes are.
Small experiments can lead to big relief.
