Samples of good nursing documentation in long term care. Bad Example “Resident understands plan of care.

Samples of good nursing documentation in long term care. Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse. Effective documentation is comprehensive, accurate, Nursing Discharge Note Examples Now that we’ve reviewed best practices for approaching the discharge summary, let’s take a look at two sample nursing notes, starting with one that fails to meet best practices. Providigm developed this QAPI Toolkit to provide staff in long term care facilities a convenient and quick reference guide. Create a standout LPN resume with 10+ customizable ATS-friendly samples and templates for 2025. This short article takes a deeper look at what daily care notes are, some tips on how to write them with ease and some examples of what good and bad care notes may look like. Most nurses notes templates include the following: Accurate nursing assessments or documentation Observed changes in the condition of a patient Care or treatment given to the patient Other relevant information to support the clinical team If you want to make the most effective notes, consider these Activity-based goals and approaches are vital to residents in long term care. The MDS is completed by a registered nurse who reviews documentation by nursing assistants to complete some parts of the MDS. however, to be successful, nursing administration must believe in, support, and promote restor- ative care. Why would the previous nurse document (paper charting), alert and oriented times three on the Dementia/Alzheimer's clients? They know their names, but, have to be repeatedly reminded where they are or how to get to the restroom throughout the day. This might include legal, professional, and institution-specific requirements. Below are two examples of a quarterly progress note. ” What is Resident-to-Resident Mistreatment (RRM)? Negative physical, sexual, or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Documentation of Activities of Daily Living (ADLs) has been a constant challenge, especially in Skilled Nursing. Oct 7, 2024 · Download our free Home Health Documentation template to help you with your document needs. In the following section, you will find nursing care plan examples related to smoking. A com-prehensive assessment is critical to understanding the factors that may have contributed to the wound’s development and/or may im-pede wound healing. Narrative nurses' notes are one of the most popular forms of nursing documentation. Additional documentation information in long-term care is discussed in Chapter 37. May 10, 2010 · I don't feel that documentation was one of my nursing schools strong lessons that they enforced. This portable handbook has nearly 300 A certified nursing assistant who has successfully completed a formal or on-the-job (or an approved external) restorative nursing educational program and has experience in long-term care and restorative nursing Nursing Narrative Note Examples Now you can generate similar detailed and comprehensive skilled nursing narrative for various health conditions using our customizable skilled nursing documentation templates. Dec 7, 2022 · These components include physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). Feb 12, 2024 · Improving Quality of Care, Improving Quality of Life for Residents by Empowering MDS Nurses, Novices and Seasoned Alike Jun 17, 2025 · Here is a starting list of events and situations that would generate the need to write a nurses note in LTC. Welcome The Registered Nurses’ Association of Ontario (RNAO) welcomes you to the second edition of the Long-Term Care Best Practices Toolkit. As a direct result of this, nursing documentation has become an increasingly important component in sustaining PDPM reimbursement. Results revealed a number of positive aspects of nurses' documentation practices and areas requiring modification or change which could be facilitated Dec 27, 2024 · Nursing Note Templates and Examples As nurses, we understand the importance of documentation. Jun 3, 2005 · Long term care, assisted living and adult day care documentation varies, it also varies state to state. Our note templates provide blocks of patient documentation that can be inserted into any note in any EMR. Jul 28, 2025 · Top-Rated Long Term Care EMR Software 2025. Feb 4, 2023 · Charting is a nursing process that includes all the documentation required from nurses. In this article, I will tell you about nursing progress notes, what they are, their purpose, and the advantages and disadvantages of using them. Under each section, there is a description of what your organization should include Jun 3, 2005 · Long term care, assisted living and adult day care documentation varies, it also varies state to state. May 1, 2021 · The fiscal management of long-term care hinges on the justification of nursing care as demonstrated in sound documentation of the services rendered. Different facilities have varying protocols for handling falls, including documentation, notification, and follow-up Source: Nursing2025 July 2008, Volume :38 Number 7 , page 19 - 19 [Free] COVID-19 Home Health & Hospice Hospitals & Clinics Long Term Care Notes Operational & Business Forms Physician & Telephone Orders Occupational Therapy Documentation Cheat Sheet Process of occupational therapy service delivery The occupational therapy process is facilitated by the distinct perspective of occupational therapy practitioners engaging in professional reasoning, analyzing occupations and activities, and collaborating with clients. In this article, we will discuss the best practices for nursing documentation, along with the importance of maintaining patient confidentiality in The cognitive loss/dementia CAA focuses on declining or worsening cognitive abilities that threaten personal independence and increase the risk for long-term nursing home placement or impair the potential for return to the community. Use this article as a resource in your practice. Oct 28, 2022 · Nursing Care Plans Once the nurse identifies nursing diagnoses related to smoking, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. Apr 25, 2018 · In response to a growing problem in drug diversion in medical facilities,CMS set the date of November 28, 2017, for long-term care (LTC) facilities—and other institutions—to implement new guidelines concerning the CMS management of controlled substances. It details nursing assessments and interventions, narrates changes in clinical status, states pertinent and relevant patient information, and provides evidence of care. The listing of records is not all inclusive. . Condition is stable. Third-Party Additional Documentation Requests When CERT requests a review, the billing provider must get supporting documentation (for example, physician’s order or notes to support medical necessity) from a referring physician’s ofice or from an inpatient facility, skilled nursing facility, or other location where records (for example, progress notes) are kept to support the services Jan 10, 2025 · Learn how to create a nursing care plan with our ultimate guide. Perhaps you are wondering Aug 7, 2023 · You face many urgent demands during your shift and charting may seem like a distraction from the work of patient care, but nursing documentation provides essential information to other healthcare colleagues on the patient’s care team and fulfills the nursing professional requirement to maintain a complete care record. To help address these common care concerns, we hosted a free webinar on fall documentation and root cause analysis with a view to helping care providers accurately record, understand, and CNA Role in Documentation When the patient functions below their capability for a prolonged period of time, functional losses may become permanent Documentation may help to qualify the beneficiary for long-term care, if needed For example, a patient inaccurately coded as independent may not qualify for additional care in the facility. Dress is appropriate, well-groomed, and proper hygiene. Sep 17, 2018 · The following are resources for documentation requirements for the LTC industry: CLICK HERE for AHIMA's Long-Term Care Health Information Practice and D Discover the importance of skilled nursing notes in patient care, enhancing documentation skills and improving healthcare outcomes with practical examples. Understanding how to effectively write these notes is crucial for nurses to ensure comprehensive and efficient patient care. Any help you provide on how to write comprehensive, narrative nursing A nursing note describes the reason for a patient’s care, interventions, their response to the interventions, and their overall progress. Facility's Plan of Correction The facility's 48 50 53 There are multiple functions of documentation: communication, record of care (goals of care, care plan: assessment, interventions, d process improvement. Each entry should seamlessly flow from the previous page, reflecting the resident's ongoing care journey. This information and materials was created by and is Jul 10, 2025 · Writing nursing progress notes in aged care involves using a structured format to ensure clarity and comprehensiveness. Such inspections are called “surveys. Is nurse charting the bane of your existence? See different examples of nursing notes and discover tips to improve your documentation skills. Garcia LJ et al. Part of the survey process is to observe the facility practice in determining the amount of A fully sprinklered long term care facility is one that has all areas sprinklered in accordance with National Fire Protection Association 13 “Standard for the Installation of Sprinkler Systems” without the use of waivers or the Fire Safety Evaluation System. Keep reading to learn about why nursing notes are important, tips for drafting your own, and a nursing note example. Clear, accurate, and timely documentation is essential to provide quality care, protect legal interests, and maintain a record of a patient’s journey to recovery. Case Study and Program Examples Example #1: Plan of Correction This is an acceptable sample PoC for Deficiency Example #1. This article describes a study of the documentation practices of nurses in a long-term care institution. They may include: Implement Restorative Nursing Programs with Confidence The risk for functional decline in long-term care residents is a serious issue that often leads to falls, pressure ulcers/injuries, weight loss, depression, and other negative outcomes. Aug 27, 2024 · Evidence-based practice (EBP) is about using the best research, clinical skills, and patient input to improve care. Don’t diagnose patients. All resident needs met at this time. When staff members participate in the QAPI Committee and/or are assigned to a Performance Improvement Project (PIP) team Members are discussing the policies and procedures for documenting falls in healthcare settings, specifically in nursing homes, hospitals, and long-term care facilities. These sections reflect the Reform of Requirements for Long-Term Care Facilities released by CMS in October of 2016 and information previously published in CMS’s QAPI tools and resources. Patient is alert and oriented to person, place, and time. Find out some of wound specialist Amy Bruggemann's top tips for preventing pressure injuries and ulcers developing in long term care settings. This guide is designed to enable you to code appropriately for your visits to patients in these varied settings. 6. It is by no means an all-inclusive list and interventions should be applied based on an individual’s needs and capabilities. Mar 14, 2024 · Clear documentation of the reason for referral is essential for therapists working in skilled nursing facilities. Our series of educational webinars cover the current problems facing long-term care, acute care, and skilled nursing facilities including fall prevention. Offering and Documenting Vaccines in Long Term Care Reporting Nursing homes must report COVID-19 and influenza vaccination information in aggregate to CDC’s National Health Safety Network (NHSN). Jul 11, 2018 · This Frequently Asked Question (FAQ) document contains questions and answers about Long Term Care (LTC) regulations, the survey process, technical questions, and other related LTC areas. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Nurses formulate nursing diagnoses in their care planning, but in everyday progress charting it is not good to speculate about possible medical diagnoses or editorialize about the issues that are going on in a patient’s life. Under the Center for Medicare and Medicaid Services (CMS) guidance to regulation F249, it states: “An activity director is responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program. In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. When therapy services are justifying Medicare coverage, nursing documentation should be consistent with therapy documentation addressing how skills learned in therapy are applied on the nursing unit. The purpose of this course is to help Healthcare professionals correctly complete process in long-term care documentation and to recognize the importance of accurate charting. The care plans are templates, with space for individualizing based on resident-specific needs. However, implementing successful restorative programs in care communities is not only invaluable to your residents' quality of life but they can also be essential sources of reimbursement. It ensures that all chart entries are clear, accurate, and consistent, which is Abstract Documentation of nursing care is an important source of reference and communication between nurses and other health care providers. It is the responsibility of the participant taking this training to read this information in its entirety. ©2019 All rights reserved. They mention assessing for injuries, notifying doctors, filling out incident reports, and informing families. By using these examples of nursing goals for yearly evaluation, you can set yourself up for success. Providers must ensure all necessary records are submitted to support services rendered. INTRODUCTION Coding and documentation have presented challenges for post-acute and long- term care physicians over the years, particularly as the continuum of care has expanded to include assisted living, subacute, and home care settings. These notes serve as a communication tool among healthcare professionals and provide a comprehensive record of the patient’s condition, interventions, and responses to treatment. Nov 25, 2023 · 4. The perfect nursing discharge note can be tough for any nurse to write. Writing activity progress notes can be time consuming but it is an important aspect of documentation. Using a small bag to store everything is recommended. I feel very weak in this area as a new nurse. EMRSystems offers a range of Top-Ranked Long Term Care (LTC) EHR, EMR, and Practice Management Software Solution demos, pricing, reviews, and comparisons. Perceptions of family and staff on the role of the environment in long-term care homes for people with dementia. the facility or agency pays up front for the care of each client. Teaching staff how to do quality improvement is no easy task. Proper documentation ensures that patient care is accurately recorded and communicated, legal and regulatory requirements are met, and quality of care is improved. The notes are typically brief, objective, and focused on essential details WHY IS DOCUMENTATION SO IMPORTANT? Did you know that in long term care (home health and SNF). Always write a detailed nurses note describing a resident's change in condition, along with a description of the prudent actions you took. Nursing progress notes help ensure patients receive high-quality care, plus they’re a legal requirement. Nov 6, 2024 · A compassionate, multidisciplinary approach can help manage one of the most complex challenges nursing homes and other long-term care providers face. . Institute of Medicine,Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes Long-term Care Pocket Guide to Nursing Documentation Elizabeth Peterson,2004-10-01 Fast Facts for the Long-Term Care Nurse Charlotte Eliopoulos,2015-04 Print+CourseSmart Improving the Quality of Long-Term Care Institute of Medicine,Division of Health Care Services,Committee on Improving Quality in In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same RECREATION AND ACTIVITY PROGRESS NOTES. Maintaining continuity and accuracy in documentation is crucial when taking progress notes in aged care. Then, the facility or agency is reimbursed for the specific care you provide after the care has already been provided and documented. Not only does it protect our patients from harm, but documentation also protects our most treasured asset: our nursing licenses! Most Electronic Health Records (EHRs) have templated solutions to fit your workflows; however, these templates do not help nurses develop simplified, streamlined ways to Nursing notes are written records that nurses maintain to document important information about the care and treatment provided to patients. Detailed vignettes and tips on effective 5 Nursing Narrative Note Examples + How to Write Written By: Darby Faubion BSN, RN One of the most important lessons nursing students learn is the importance of documentation. But it doesn’t have to! This list of Examples of Evidence-Based Practice in Nursing with Research keywords Determining food intake by facility staff, family, or by volunteers is an important part of monitoring the food/fluids consumed by residents. Let’s break down how to write nursing progress notes. Jun 7, 2023 · Measurable objective and interventions must be documented in the care plan and in the medical record. In Nursing Notes Examples conclusion, nursing notes play a vital role in patient care and healthcare communication. Under this prohibition Sep 20, 2024 · Conclusion Setting nursing goals for yearly evaluations is more than just a task on your to-do list. International Psycho geriatrics 2012; 24(5):753-65. You do not want to over document, creating repetitive forms and wasting your time Jun 22, 2022 · Long-term care employers, who have recognized the need to develop career advance-ment programs for the Certified Nursing Assistants (CNAs) who make up the bulk of the work force in skilled-nursing facilities (SNFs); INITIAL CARE PLAN Please complete this plan within 48 hours of admission by admission nurse. Good clinical practice would indicate that the results of this reassessment should be documented in the The MDS is a standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. About the surveys What are surveys? The ofice of long-term care services for each state’s Department of Health Services – the Assurance and Licensure Services Division – inspects nursing homes that provide care to Medicare and Medicaid clients using federal standards. Introduction and Acknowledgements This book is intended as a starting point for practitioners in the long-term care setting. It’s an opportunity to grow, improve patient care, and build a more fulfilling career. For nursing students or professionals—whether you’re working on a BSN, MSN, DNP, or just staying updated—choosing the right EBP project ideas can feel overwhelming. Appropriate and accurate documentation will aid health care providers in the monitoring of a patient’s progress Barriers (and Solutions) to Successful Programs Potential Candidates for Restorative Program Algorithm Restorative Documentation Requirements Checklist Restorative Process Restorative Staffing Models: Dedicated Aide or Shared Responsibility Restorative Program Manager and Nursing Leadership Sample of Program Goals and Program Activity Section Guide Upper Extremity Active Range-of-Motion The Solution Our goal at NP-Notes is to save you hours in documentation and improve your efficiency. You do not want to over document, creating repetitive forms and wasting your time Jun 22, 2022 · Long-term care employers, who have recognized the need to develop career advance-ment programs for the Certified Nursing Assistants (CNAs) who make up the bulk of the work force in skilled-nursing facilities (SNFs); Oct 26, 2024 · Here are nursing care plan examples, a guide on writing a nursing care plan, nursing intervention, and the nursing process, including using the NANDA outline. Understanding Medicare documentation guidelines for skilled nursing facilities can get complicated. This includes the completion and/or directing/delegating the completion As a nurse, you know that documentation is a critical aspect of your job. Discover essential steps, examples, and tips for success in writing your care plan. Effective d re and patient safety. So how can restorative programming be effectively implemented Sample Of Good Nursing Documentation: Nursing Care Plans & Documentation Lynda Juall Carpenito-Moyet,2009 The Fifth Edition of Nursing Care Plans and Documentation provides nurses with a comprehensive guide to creating care plans and effectively documenting care This user friendly resource presents the most likely diagnoses and collaborative problems with step by step guidance on nursing Learn how to write effective and accurate nurse care (visit) notes using structured methods like ISBAR and SOAPIE. ” Feb 19, 2025 · Here’s a refresher on what and how to chart as a nurse, as well as tips for avoiding some of the most common documentation mistakes. Learn how to write care plans in this guide! Sep 10, 2024 · Because providers rely on documentation to communicate important patient information, incomplete and inaccurate documentation can result in unintended and even dangerous patient outcomes. Drug Enforcement Administration (DEA), which has oversight authority for the CSA, a nurse in a long-term care (LTC) setting (nursing home, assisted living facility, and hospice) is prohibited from serving as an “agent” of a practitioner prescribing a Schedule II-V medication for a LTC resident. Oct 10, 2024 · Nursing admission notes are a critical aspect of patient care, serving as the foundation for the treatment plan and ensuring continuity of care. Kate Stout Chart Smart Lippincott Williams & Wilkins,2011 Chart Smart: the A-to-Z Guide to Better Nursing Documentation tells nurses exactly what to document in virtually every type of situation they may encounter on the job, no matter where they practice--hospital, medical office, outpatient, rehabilitation facility, long-term care facility, or home. Some examples of charting include documenting medications administered, vital signs, physical assessments, and interventions provided. Apr 22, 2022 · Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. There are many ways to complete progress notes. they must expect the best and make When do you use nursing notes? These notes are used in hospitals, long-term care facilities, and home health settings to document ongoing nursing care. Mar 24, 2025 · Use a nursing notes template enabled with AI: 1) nursing charting template; 2) nurses notes template; and more templates with examples. Texas Health and Human Services This form is designed to assist the nursing, housekeeping, and maintenance departments survey the facility’s environment for hazards and ensure that regulatory compliance guidelines are in place. Jun 21, 2022 · This long term care documentation example acts as a guide to the charting required in LTC. O National Center for Biotechnology Information fornece acesso a artigos científicos e informações relacionadas à biotecnologia e saúde. Oct 28, 2020 · How do you write a nursing note? Nursing notes are health or medical records written by a nurse. Sep 27, 2024 · Discover 30 expertly crafted long-term care nurse resume examples and templates to elevate your job application and stand out in the healthcare industry. Under an interpretation adopted in the past several years by the U. Patient-specific clinical findings and other documentation supporting a life expectancy of 6 months or less Guidance: The certification should give specific clinical findings, for example, signs, symptoms, laboratory testing, weights, anthropomorphic measurements, oral intake Therapy services and intellectual property provided by Functional Pathways. With ongoing nurse shortages and the increasing pressure put on long-term care professionals, restorative nursing programs are often overlooked. RNAO is delighted to provide this key resource to you, developed by the Long-Term Care Best Practices Program. Restorative care is a philosophy of plain, holistic nursing care that may be provided at long-term care facilities, subacutes, long-term acute care facilities, home health care, and acute care hospitals. Jan 30, 2019 · Database and list of nursing care plans (NCP) examples and nursing diagnoses for student nurses. Read it carefully, and then click on each of the blue criterion tab buttons below to see how it meets the five criteria for evaluating acceptable PoCs. Mar 1, 2007 · Questions and Answers about Resident Documentation, Care Planning, MDS's, Quarterly's, Activity Attendance Records 100 Fall Interventions This list is created to assist facilities in choosing fall interventions. 11 Sample Documentation Sample Documentation of Expected Findings Patient denies any new onset of symptoms of headaches, dizziness, visual disturbances, numbness, tingling, or weakness. For line staff, webinars and PowerPoint presentations are not the best teaching methods. Bad Example “Resident understands plan of care. Whether you are a nursing student or a seasoned nurse, knowing how to create accurate nurses' notes is vital. The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix C. Jun 17, 2025 · Here is a starting list of events and situations that would generate the need to write a nurses note in LTC. Comparing food/fluid intake over time is a way to evaluate trends in a resident's nutritional status such as, low intake and the possibility of changes in weight. Here are three best practices for facilities to help guide your staff. Why Write Nursing Notes? Nursing Jun 18, 2024 · Skilled Nursing Facility (SNF) Documentation Requirements It is expected that patient's medical records reflect the need for care/services provided. It covers the importance of ADL documentation in skilled nursing facilities, challenges in accurate ADL coding, strategies for improving documentation accuracy, and the impact on patient care planning, MDS assessments, and reimbursement under the AHIMA's Long-Term Care Health Information Practice & Documentation Guidelines Please note: Portions of these guidelines are under revision to reflect regulatory and practice changes. Implement Restorative Nursing Programs with Confidence The risk for functional decline in long-term care residents is a serious issue that often leads to falls, pressure ulcers/injuries, weight loss, depression, and other negative outcomes. To write your organization’s written QAPI plan using this how-to-guide, use the numbered sections, highlighted in gold. Jun 17, 2025 · Here is a starting list of events and situations that would generate the need to write a nurses note in LTC. This article provides a comprehensive guide for healthcare professionals on effectively reviewing Activities of Daily Living (ADL) documentation. Sep 4, 2024 · Good documentation is a necessary part of building your nursing career and protecting your licensing. Jun 24, 2014 · Hi All Nurses, I would really appreciate your guidance once again. Wound healing begins with the assessment of the patient and the wound, and proper documentation by the health care provider. Learn the importance of good home health documentation. Find specialty EMR Software latest updates. Dialysis patients coming from your long-term care facility to the dialysis facility for treatment need to bring the items listed on the following page. Documentation is an integral part of healthcare, so honing this skill is definitely worth your time. Why Write Nursing Notes? Nursing Mar 14, 2024 · Clear documentation of the reason for referral is essential for therapists working in skilled nursing facilities. In this blog post, we’ll explore the importance of documentation in nursing and provide tips and strategies for nurses in long-term care and hospitals May 7, 2024 · Nursing documentation is an essential aspect of patient care and plays a pivotal role in enhancing communication between healthcare professionals, recording medical history accurately, and providing legal protection for registered nurses (RNs). Here’s a breakdown to help your compliance team. Residents aged 65 and ab … A nursing note describes the reason for a patient’s care, interventions, their response to the interventions, and their overall progress. I will also share 5 perfect nursing progress notes examples + how to write them. NHSN also allows for reporting of individual resident’s vaccination information. Feb 20, 2025 · Enhance your nursing documentation skills, learn to capture patient information efficiently, and prepare for a successful nursing career. With the right documentation, nurses can show effective communication and even more importantly, demonstrate commitment to quality patient care. Download as PDF or edit for free. How to Write Nursing Notes (20+ Nursing Note Examples) A nursing note is a medical or health record that is made by a nurse that shows accurate documentation of nursing assessments, changes in patient’s conditions, care provided, and related information to support the clinical team to deliver excellent care. Nursing documentation is essential for communicating clinically relevant information to the healthcare team. I am looking for help to strengthen my nurses notes. It is my goal that the care plans and RAP templates will be useful to beginners and experienced Resident Assessment Coordinators, as well as other interdisciplinary team Nov 1, 2017 · This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Helpful hints and tips within the templates can improve patient care and save time. Jan 8, 2025 · A Nurse Charting Cheat Sheet is a quick reference guide designed to help nurses adhere to proper documentation protocols when recording patient information. Review by DON All problems and goals and interventions will be reviewed and replaced by a comprehensive care plan (21 days after admission) Mar 24, 2025 · Use a nursing notes template enabled with AI: 1) nursing charting template; 2) nurses notes template; and more templates with examples. This tool streamlines the charting process by consolidating essential rules, formatting tips, and standard abbreviations into an easily accessible format. Use these tips for documenting care correctly. Do you need to hone your note-taking skills as a nurse? This guide covers tips for charting effectively and different types of nursing notes with examples. Newly added questions and answers are in red font and older questions and answers are in black font. S. Also find out how documentation can help you avoid getting cited with an avoidable pressure ulcer. zjar adjfw nhdaw xyhf httneyo kcggl ago cepyb xycslbl klpvwkj