🧠 1. What Is Documentation & Why It Matters

Documentation is a vital nursing responsibility. It must:

• Allow the team to retrieve clinical data fast
• Track patient outcomes
• Ensure continuity of care

📌 EVERY nursing action must be documented.

📚 2. Purposes of the Health Care Record

Documentation is used for:

🔐 3. Privacy, Confidentiality & Security

Nurses MUST:

• Keep all patient information confidential. Only discuss the patient with the health care team
• Follow HIPAA rules
• Ensure physical + electronic protection of records (passwords, filters, restricted access)

Printed documents must be destroyed when done.

💡 NCLEX TIP:

“If someone asks for patient information and they’re not in the care team → Answer is ALWAYS NO.”

💻 4. Electronic Documentation (EHR vs EMR)

EHR (Electronic Health Record) = long-term, multi-setting patient record

EMR (Electronic Medical Record)= Record used within one facility

The HITECH Act promotes “meaningful use” of EHRs to improve quality & lower costs.

📝 5. Standards of Quality Documentation

Your documentation must be:

F.A.C.C.O , sounds like F#ck!

✍️ 6. Documentation Methods

📌 Flow Sheets – quick trends (Vital Signs, Input and Output)

📌 Charting by Exception – only document abnormalities

📌 POMR (Problem-Oriented Medical Record ) – organized by patient problems

📌 Progress Notes – narrative or structured notes

Progress Note Formats:

🗂 7. Common Forms in the EHR

• Admission history form
• Patient care summary
• Care plans
• Discharge notes

☎️ 8. Documenting Communication & Events

You MUST document:

• Every telephone call to a provider
• Telephone/verbal orders (Verbal Order is discouraged except in urgent or emergent situations)
• Incident (Occurrence) Reports

Incident reports:

→ Used for quality improvement, NOT placed in the patient chart.

📊 9. Acuity Rating Systems

It’s a tool used to determine:

• Hours of care and staffing needs for a patient.

Based on # of interventions needed in 24 hours.

🏡 10. Documentation in Long-Term & Home Care

Long-Term Care (LTC)

• Regulated by TJC, CMS, State regulations
• Must use RAI, including MDS + CAA

Home Health ⇒ O for hOme

Documentation must justify reimbursement:

• Uses OASIS
• Uses Omaha System

🧭 11. Case Management & Critical Pathways

• Interprofessional care plans with timelines
• Expected outcomes
• Identify variances (unexpected outcomes or unmet goals)

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🧑‍💻 12. Nursing Informatics

Integrates:

• Nursing science
• Computer science
• Information science

Used to manage:

→ Data → Information → Knowledge → Wisdom

🧪 NCLEX Quick Questions

1️⃣ Why can’t we release patient info to non-team members?

✔ A. Because of legal and ethical obligations to maintain confidentiality.

2️⃣ When documenting an admission, what should the nurse record?

✔ B. Objective data that are observed.

3️⃣ “Patient states abdominal pain is worse.” What documentation type?

✔ C. Narrative charting

4️⃣ Purpose of an incident report?

✔ D. To help the hospital’s quality improvement program

🔥 NCLEX TIPS (High-Yield)

✔ NEVER chart:

• Opinions
• Blame
• “Seems,” “appears,” “I think”
• Incident report details in the EHR

✔ ALWAYS chart:

• What you saw
• What you did
• How the patient responded
• Exact quotes in quotation marks
• Exact times

✔ If it wasn't documented → It wasn’t done.

✔ Telephone orders:

• Repeat back
• Document immediately
• Provider must sign later

✔ Charting by exception:

• Only chart abnormal findings
• Requires strong baseline assessment