Christina Rafano covers five documentation rules for nursing students: chart immediately after care, use a brain sheet first, record the full assessment-intervention-response cycle, master your EHR system, and stick to approved abbreviations. These practices matter for accurate charting and NCLEX success.
And this is a huge NCLEX point for you, okay? If you didn't document it, it didn't happen. So the first rule of documentation is to document everything and do it right away. Not early, don't document late, but right away after you do anything. Now rule number two is to use a brain sheet. I love these. As a nursing student, you are soaking in so much information and there's just no way, no way that you're going to remember everything. This really creates a reliable referen when you go sit down to officially chart after your assessment. So trust me, this will save you so much time. It'll make your documentation way more smooth and reliable and accurate. Now rule number three is to document the full cycle of patient care. This is huge for the nclex, my friends, they love testing this. So you need to document three things in order, all right? Assessment always comes first. Always document what you found before you do anything. Like any nursing intervention or anything. Then the intervention, what action did you take? And then the patient's response. How did the patient respond to your nursing interventions? Rule number four is to master your electronic health record system. More you practice with these systems, the faster and more accurate that you will get at it. Rule number five is to only use approved abbreviations. This is big one big NCLEX point here, my friend. When in doubt rule, write it out. So stick to your facility's approved abbreviation list and the Joint Commission guidelines. Write it out anytime you're doubtful.
