Bootcamp

Charting · Shift 1

Patient Face Sheet
Camille Whitcombe
58 y/o · Room 412
Post-op Day 1 — Laparoscopic Cholecystectomy
Allergies
NKDA
Code Status
Full Code
Shift
0700 Day Shift
Charge Nurse
Nurse B
Nurse B
Nurse B pre-shift
Welcome to your charting shift, Nurse

Welcome to your charting shift, Nurse. Today you'll document patient care as it happens throughout the shift. Each charting opportunity will require you to decide where the information belongs in the EMR and document it professionally. I'll coach you after every chart entry, whether it's excellent, acceptable, or needs improvement. If you get stuck, your Charge Nurse is available for guidance. At the end of the shift, I'll review your overall documentation and determine whether you're ready to move on.

EMR tabs available
Assessment
Vital Signs
Pain
MAR
Provider Communication
Intake & Output
Education
Notes