Documentation Basics
What does "objective data" mean in documentation?
What is information you can observe or measure (e.g., vitals, physical assessment). Use objective statements; describe what was seen, said, or done, and do not include your own personal opinions. Document subjective statements with direct quotations.
What should you do if you make an error in a paper chart?
What is draw a single line through it, write “error,” and initial/date it
What does “PRN” mean?
As needed
What does PHIPA protect?
What is patient health information and privacy.
What does SBAR stand for?
What is Situation, Background, Assessment, Recommendation
True or False: You can use white-out to correct charting mistakes
What is false.
True or False: It's okay to chart care before you give it.
What is false.
What’s wrong with using “QD” in documentation?
It's a dangerous abbreviation; should write “daily” instead
When does the updated CNO Documentation Standard go live?
What is February 1, 2026. You will be held accountable to the most recent version of this standard.
You’re calling the MRP about a patient with low blood pressure. What would you include in the “Situation”?
What is identify self, site/unit you are calling from, identify the patient you are calling about, the problem (i.e., low blood pressure), onset and severity.
Name three characteristics of good documentation
What is clear, complete and accurate.
It is okay to copy and paste/drag and drop/recall values.
What is fale. The practice of “cutting and pasting” of any information in the Meditech electronic medical record is strictly prohibited under policy #DOC-2-06 and is considered to be a falsification of the patient record and a failure to meet the CNO Documentation Standard of Practice.
Give the correct abbreviation for “nothing by mouth.”
NPO
Is it okay to chart in advance if you're running behind?
What is no. According to CNO's Documentation Standard of Practice nurses must document in a timely manner, either at the time care is provided care or as soon as possible after the care or event occurred. Nurses do not document before the care is provided.
What information is typically included in the “Background” section?
What is date/time of admission, admitting diagnosis, relevant medical history, lab/diagnostic results, and notable changes.
What is our organization's documentation policy that you are held accountable to?
What is Clinical Documentation Standard [DOC-2-06].
Name one consequence of poor documentation.
What is potential patient harm, communication failure, disciplinary action or legality.
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.
What is false. Access to health information is based on the "need to know" principle to provide current and direct patient care or to perform one's duties.
You assess the patient and determine they may need fluids. What part of SBAR does this go under?
What is recommendation.
Why is it important to document nursing interventions promptly?
What is patient safety, effective communication, delivery and continuity of care, meeting the documentation standard and supporting legal and professional accountabilities. Delaying documentation increases the risk of errors and can compromise the quality of care provided.
What is a “late entry” and how do you document one?
What is when you forget to document something earlier. Indicate late entry, the date and time the care and/or action occurred then document the care and/or action that occurred.
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 documentation when you walk away from your computer at the nursing station or down the hall?
What is lock your screen when stepping away from the computer.
SBAR Challenge: Create a complete SBAR statement for a patient with chest pain and a history of cardiac issues.
What is:
S -
B -
A -
R -