Documentation Basics
What does "objective data" mean in documentation?
Information you can observe or measure — e.g., vitals, physical findings)
What should you do if you make an error in a paper chart?
Draw a single line through it, write “error,” and initial/date it
What does “PRN” mean?
As needed
What does HIPAA protect?
Patient health information/privacy
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
True or False: You can use white-out to correct charting mistakes
True or False: It's okay to chart care before you give it.
False
What’s wrong with using “QD” in documentation?
It's a dangerous abbreviation; should write “daily” instead
Can you share a patient’s chart with a friend who’s a nursing student?
No, that violates HIPAA
You’re calling the provider about a patient with low BP. What would you include in the “Situation”?
Brief statement of the current issue, e.g., “Patient’s BP is 84/50 and symptomatic
Name three characteristics of good documentation
Accurate, timely, objective — others include concise, complete, legible)
You see another nurse document vitals that weren’t taken. What should you do?
Report the incident per facility policy — possible falsification
Give the correct abbreviation for “nothing by mouth.”
NPO
Is it okay to chart in advance if you're running behind?
No — documentation must reflect real-time care
What information is typically included in the “Background” section?
Relevant medical history, diagnosis, recent vital signs, meds, or events leading to this moment
What is the first thing you document in a shift?
Patient Assessment
Name one consequence of poor documentation.
Legal liability, patient harm, communication failure, disciplinary action
What does “WNL” mean, and why should you use caution with it?
Within Normal Limits; may be too vague or not accurate
True or False: You can access charts of patients not assigned to you
False — unauthorized access is a violation
You assess the patient and determine they may need fluids. What part of SBAR does this go under?
Recommendation
Why is it important to document nursing interventions promptly?
To maintain continuity of care, avoid errors, ensure legal protection
What is a “late entry” and how do you document one?
When you forget to chart something earlier; document with "Late Entry," date/time of event, reason for delay
Identify the correct abbreviation: “subq” or “SC” for subcutaneous?
subq; SC is not recommended by Joint Commission
What’s a secure way to protect your charting station?
Log out/lock screen when stepping away
SBAR Challenge: Create a complete SBAR statement for a patient with chest pain and a history of cardiac issues.
Mrs. Vines' decision is..............