Principles
Methodology
Professional & Legal Responsibilities
SBAR Communication
DON'T-cumentation
100
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.
100
Every clinical specialty has a ___ of ___ and an associated policy outlining the minimum standards for documentation.
What is a standard of care.
100
Who is responsible for the regulation and legislative requirements for nursing documentation?
Who is the College of Nurses of Ontario (CNO).
100
What does SBAR stand for?
What is Situation, Background, Assessment, and Recommendation. 
100
True or False: Documentation should reflect your thoughts, opinions and perspectives.
What is false. Your documentation should communicate your patient's needs, goals, choices and preferences.
200
True or False: You can use white-out to correct paper charting mistakes.
What is false, never use whiteout or obliterate the text; instead, draw a single line through the mistake, write "error," and add the date, time, and initials, then document correctly in the next available space.
200
The frequency of documentation is determined by...
What is the patient's condition.
200
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.
200
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.
200
True or False: It's okay to chart care before you give it.
What is false. 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.
300
Name three characteristics of good documentation.
What is clear, complete and accurate.
300
True or False: You can chart by exception.
What is true, as long as you "view protocol" and agree you can select "within normal limits".
300
Who is likely to benefit the most when you ensure that documentation (e.g., Kardex) is clear and up-to-date with relevant information, especially at shift change?
Who is your colleagues.
300
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.
300
True or False: 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.
400
What is our organization's documentation policy that you are held accountable to?
What is Clinical Documentation Standard [DOC-2-06].
400
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. Meditech allows for edits/amendments within 72 hours.
400
Who supports nurses with policies, procedures and decision making tools to support documentation?
Who is the organization (e.g., Thunder Bay Regional Health Sciences Centre).
400
You assess the patient and determine they may need fluids. What part of SBAR does this go under?
What is recommendation.
400
Name one consequence of poor documentation.
What is potential patient harm, communication failure, disciplinary action or legality.
500
Why is it important to document contemporaneously (as close to real time as possible)?
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.
500
What is the formatted structure of nursing notes, what does it stand for, and when should you use them.
What is Focus, Data, Action, Response, Plan (FDARP) and to help clarify a specific patient problem, concern, or event (e.g., fall, change in condition).
500
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. 
500
SBAR Challenge: Create a complete SBAR statement for a patient with chest pain and a history of cardiac issues.
What is...
500
What is required prior to documenting relevant communication with family members in the patient's chart?
What is patient consent.