User Guide — Nursing Documentation Tools

Use the admission note to document:

• Patient's initial assessment
• Historical chart information
• Initial nursing care plan

Review and update the nursing care plan to keep the nursing team on track. Address and resolve issues with patient care:

• Nursing diagnoses
• Goals
• Interventions
• Ideal outcomes

Task lists are automatically generated from nursing orders. Review the task list to see what tasks you will need to complete for each patient during your shift:

• Scheduled tasks
• Continuous tasks
• PRN tasks

Track medication orders and their administration,

using either barcode scanners or manual entry.

• Administered
• Not given
• Rescheduled
• Acknowledge discontinued

Communicate brief updates to the entire care team, such as:

• Location of patient
• Communications with care team

Flowsheets allow the entire care team to view multiple aspects of a patient's health over time, and spot trends at a glance.

Enter data that you want to track over the course of a stay to assess how a patient's condition is changing. Flowsheets reduce the need to research shift notes for critical data, reduce patient safety risk, and can improve continuity of care and patient outcomes. Nursing flowsheets track:

• ADLs
• Airways
• Assessments
• Drains
• Lines
• Measurements
• Restraints
• Screenings
• Tubes
• Vitals
• Wounds

Use shift notes to document:

• Your current shift
• Notable events

You can access templates for structured documentation, including:

• Documenting your shift assessment
• Head-to-toe assessments
• Lines, tubes, and drains
• Screening questionnaires
• ADLs