A nurse explains five documentation rules tested on the NCLEX: chart immediately after each action, use a brain sheet to track assessments, record the full Assessment-Intervention-Response cycle, master your facility's EHR system, and stick to approved abbreviations. Bad charting risks patient safety, legal trouble, and your license.
Bad documentation in nursing school can literally put your patient's life and your nursing license at risk. So in this video, I'm walking you through five must know rules for perfect documentation that will make you a charting rock star in nursing school. So hit that subscribe button and click the notification bell and let's dive in. Alright? So you know how I love to make nursing content so simple for you. And when it comes to patient documentation, there is one, one really, really golden rule that is above everything that we do as nurses. And this is a huge NCLEX point for you, okay? If you didn't document it, it didn't happen, all right? No documentation means you didn't do it. This isn't just some catchy catchphrase that your instructors like to throw around. This is literally the foundation of patient safety in nursing school and nursing legal accountability and team communication between the healthc. Even if you do the most perfect nursing assessment or give the most perfect medication and do it correctly, if it's not documented in the patient's chart, it's invisible to everyone else. And it's invisible legally. Didn't happen, doesn't exist. So let's break this down into super simple steps that will make you a documentation rockstar, my friend. I've got five golden rules for you that will keep you and your patients safe. Safe. So I put all of these tips in my free clinical cheat sheet for you as well. So be sure to snag that the link is down below in the description. 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 here's a scary scenario for you to consider. Imagine that you give your patient their morning insulin dose before breakfast, but you get busy and you forget to chart it. And then a well meaning nurse colleague checks the chart, sees that the insulin was not given and then administers a second dose. Now this could literally kill your patient from hypoglycemia, right? Huge, huge problem. So here's your key critical thinking point. Prompt documentation prevents medication errors for your patient and keeps the patient's record current. So waiting until the end of your shift to chart for all of your patients during that day, that is a recipe for disease disaster, my friend. And it's a legal nightmare just waiting to happen. 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 so think of your brain sheet as kind of your GPS system for your assessments. So just like a GPS guides you turn by turn your brain sheet, it's going to guide you through each part of your head to toe assessment or your focused assessment. So jot down notes on your brain sheet during your nursing assessments with your patients, okay? This really creates a reliable reference 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 first 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? Now here's a memory trick. Think air, A I R assessment, intervention and response. All right? Just like you need air to breathe, we all do. You need air to document properly. Now let me give you an example here. If you check your patient's blood pressure and it's 180 over 100. So that's your assessment part. So document that. Then when you give their blood pressure medication, then that is what your nursing intervention would be. You give that blood pressure medication. So you document that it was given. Then you must go back about an hour, recheck their blood pressure, all right? And then you document that result. That's the response. So this cycle of your nursing assessment, intervention and response, this is critical for documentation and legal protection. Now, rule number four is to master your electronic health record system. So most facilities use an EHR system now. And here's the deal, the more you practice with these systems, the faster and more accurate that you will get at it. So take every single opportunity that you can to practice navigating your facilities ehr. So speed and accuracy and charting, it's going to make your life so much easier. So personally, I liked showing up to clinical early to get my patient assignment if they had it available for me. And I would flip through the patient's charts well before my clinical day even started. So if your facility and if your school and your clinical instructor, if they allow that doing that can be so helpful for you as you get used to the EHR system. And it will also really just give you a head start on your day because you already know what's going on with those patients that you have assigned to you that day. And rule number five is to only use approved abbreviations. This is a big one. So here's a critical thinking point for you, okay? Ambiguous abbreviations? These can be deadly. Imagine that you're trying to figure out what BLCLWR means. I don't like that one. Does it mean blood labs came back low, will repeat, or bed lowered, call light within reach? You can see why I don't like that one, right? Big NCLEX point here, my friend. When in doubt, write it out. So stick to your facility's approved abbreviation list and the Joint Commission guidelines. Write it out anytime you're doubtful. Abbreviations are a big deal. The NCLEX loves patient safety questions and documentation is a huge, huge part of that. So if you struggle with answering NCLEX style questions in nursing school and choosing the most correct answer on your exams, you definitely want to check out this video here where I walk you through the absolute top strategies for choosing the correct answer on your nursing school exams. And if you like step by step guides for nursing school like this one, write love in the comments below because that is just what we do around here, my friend. Hit that subscribe button and click the notification bell. And as always, my friend, go become the nurse that God created only you to be. And I will see you over there in that next video.
