If it was not documented, it was not done — and if it was documented but not done, that is fraud. Four stations: rebuild a vague note out of measurements and quotations, put the exam in the order you actually performed it, describe skin findings so they are not missed in darker skin, and fix the abbreviations that have killed people.
Rebuild the note
Tap every fragment that belongs in a defensible entry. Watch the note and the critique build on the right — and watch what happens when you tap an adjective.
Order the examination
Choose a region, then tap the four techniques in the order you would actually perform them. You chart in the order you assessed, because the order is part of the technique.
Tap techniques below to build the sequence.
Find it in every skin tone
Choose a finding, then select every site you would assess. Textbooks describe these findings as they appear in lightly pigmented skin, and students then miss them entirely in patients with darker skin.
Fix what cannot be written
The Joint Commission Do Not Use list applies to all orders and to all handwritten and free-text documentation. Choose the safe rewrite for each line.
The nurse’s note
Nothing charted yet.
Six rules for every entry
Timely — as close to the event as possible and never in advance. Charting a medication before you give it is falsification even if you intend to give it in two minutes.
Accurate and objective — what you saw, heard, measured and did; not what you concluded about the patient’s character.
Complete — assessment, intervention, the patient’s response, and any notification with its time.
Legible and permanent — black ink, no pencil, no erasures, no correction fluid.
Attributed — your own signature and credentials or your own login. Never share a password; never chart under anyone else’s.
Chronological — the facility clock, usually 24-hour time, with late entries labeled as late entries.