Documentation and Reporting - Fundamentals of Nursing

Picmonic helps you not just memorize, but truly understand the importance of clear and concise documentation in nursing. You'll learn best practices for accurate reporting, ensuring smooth communication with the healthcare team and ultimately, better patient care. Become a confident nurse who excels in documentation with Picmonic by your side!

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Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett | Registered Nurse (RN) School Study Aid

Documentation Guidelines

Objective Information

Subjective Information from Patient

Objective Supports Subjective

Avoid Unnecessary Words and Details

Exact Measurements

Assessments

Document ASAP

Treatment and Response

Change in Status

Admission, Transfer, Discharge or Death

Document in a Logical Order

Ensure Information Recorded is Complete

4 mins

Reports

Shared Communication

ISBAR

Identify

Situation

Background

Assessment

Recommendation

Change-of-Shift/Handoff Reports

Telephone/Telemedicine Reports

Transfer and Discharge Reports

2 mins

I-SBAR-R

Identify

Situation

Background

Assessment

Recommendation

Readback

1 min

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