Exam 1 Blueprint Study Guide PDF

Exam 1 Blueprint Study Guide **[5 CHARACTERISTICS OF NURSING:]** - Nursing practice is individualized - Nurses coordinate care by establishing partnerships - Caring is central to the practice of the Registered Nurse - Registered Nurses use the nursing process to plan and provide ind...

Exam 1 Blueprint Study Guide **[5 CHARACTERISTICS OF NURSING:]** - Nursing practice is individualized - Nurses coordinate care by establishing partnerships - Caring is central to the practice of the Registered Nurse - Registered Nurses use the nursing process to plan and provide individualized care to their healthcare consumers - A strong link exists between the professional work environment and the registered nurse's ability to provide quality health care and achieve optimal outcomes. **[SENC:]** (Safe Effective Nursing Care- Thinking, Doing, Caring) - Provide goal directed patient care - Collab with the interprofessional health care team - Validate evidence based on research to incorporate into practice - Provide safe quality client care - Embrace and incorporate technological advances **[Nursing is a Profession, Discipline, and Occupation. ]** **[Profession:]** The knowledge of the group must be based on technical and scientific knowledge. The knowledge and competence of members of the group must be evaluated by a community of peers the group must have a service orientation and a code of ethics. **[Discipline:]** It is a scientifically based and self-governed profession that focuses on the ethical care of others it is a discipline driven by aspects of theory and practice it demands mastery of both theoretical knowledge and clinical skills. **[Occupation:]** Nursing involves performing tasks and providing a service in exchange for payment. **[Professional Organizations: ]** - ANA -- American Nursing Association National (professional\ organization) - NLN -- National League for Nursing (Establishes and\ maintains a universal standard of education) - ICN -- International Council of Nurses (Federation of national\ nursing organizations) - **[QUALITY AND SAFETY EDUCATION FOR\ NURSES (QSEN)]**\ Formed by nursing leaders in 2005 to improve the quality of\ nursing education\ [Six competencies]:\ 1. Patient-Centered Care\ 2. Teamwork & Collaboration\ 3. Evidence-Based Practice\ 4. Quality Improvement\ 5. Safety\ 6. Informatics - **[Federal Laws Guiding Nursing\ Practice]**\ Bill of Rights\ Health Insurance Portability and Accountability Act\ (HIPAA)\ Emergency Medical Treatment and Active Labor Act\ Health Information Technology for Economic and Clinical\ Health (HITECH)\ Patient Self-Determination Act (PSDA)\ Americans with Disabilities Act (ADA) - **[State Laws Guiding Nursing Practice]**\ Mandatory reporting laws\ Communicable diseases (ex: TB, Meningitis, Hep B)\ Abuse\ Good Samaritan laws\ Differ by state\ Nurse practice acts: laws that govern nursing\ practice\ Protect the health, safety, and welfare of the general\ public\ Defines credentialing, licensing and discipline - **[REGULATION OF NURSING PRACTICE]**\ Nurse practice acts: laws that govern nursing practice\ ↑ Protect the health, safety, and welfare of the general public\ State board of nursing\ ↑ Approves nursing education programs\ ↑ Define the scope of practice for nurses in that state\ ↑ Establish criteria for licensure\ ↑ Disciplinary action and enforce laws\ Professional Standards -- Duties that all nurses should\ perform competently. - **[Malpractice:]** a type of legal liability in which a professional fails to act in a reasonable and prudent manner. (Happens when standards are not followed.) - Malpractice: Four elements must be proven:\ [Existence of a duty] -- the nurse has a legal\ obligation\ [Breach of a duty] -- fails to meet standard\ of care\ [Causation] -- the breach of duty is direct\ cause of harm\ [Damages] -- money paid for malpractice\ **[Nurses can get their own malpractice insurance]** - - **[Torts and Nursing Practice]**:\ Quasi-intentional torts\ Defamation of character- False communication to a third person\ Slander- Oral defamatory statements\ Libel- Written defamatory statements\ **[Intentional torts\ ]** Assault and battery- Performing a procedure without consent\ False imprisonment- Restraining a patient against their will\ Invasion of privacy- Breach of confidentiality\ Fraud- Failing to provide essential information for informed consent - Torts and Nursing Practice (cont)\ Negligence and Malpractice\ Negligence is the failure to take reasonable care to prevent harm (to perform as a reasonable,\ prudent person would)\ Malpractice is a form of negligence in which a professional is aware of potential risks to cause harm\ Failure to follow standards of practice\ No intent to harm is present. - - **[The Healthcare Delivery system:]** - What type of care is provided?\ **[Acute care:]** The goal is to prevent deterioration and restore health. Trauma/acute surgery, emergency, urgent, short-term, prehospital (urgent care,\ clinic), critical\ **[Long-term support services]**: Nonhospital settings (extended care, ambulatory centers, home health). Encompass "human assistance, assistive technologies and devices, environmental modifications, care and service coordination" on a regular or intermittent basis. - **[Healthcare Categorization]**:\ **[Primary:]** Illness prevention and health promotion. Education, vaccinations, etc.\ **[Secondary:]** Diagnosis and treatment of disease or injury\ **[Tertiary]**: Long term rehabilitation and end-of-life care - - **[INTERPROFESSIONAL HEALTHCARE TEAM]**:\ Physicians (MDs or DOs)\ Advanced practice nurses\ (APNs)/nurse practitioners (NPs)\ Physician assistants (PAs)\ Registered nurses (RNs)/licensed\ practical nurses (LPNs)\ Unlicensed assistive personnel (UAPs)\ Pharmacists\ Therapists (respiratory, physical etc)\ Technologists (radiology, lab) - Recreational drugs - Job - Recreation 3\. **[Cognitive/Sensory Issues:]** \- Confusion \- sensory loss\ 4. Communication\ 5. **[Mobility:]** \- Fall risk\ 6. **[Physical and Emotional State:]** \- Stamina Strength \- Depression **[Safety: Hazards in Patient Environment]**\ 1. Hazards in the home\ - Poisoning\ - Burns\ - Fires\ -Suffocation/asphyxiation\ 2. Hazards in the Community\ - Motor vehicle accidents\ - Pathogens: foodborne, vector-borne, waterborne, person-to-person, droplet, airborne\ -Pollution\ -Weather 3\. Hazards in the Healthcare Environment:\ -Equipment related accidents\ -Alarm safety\ -Fires and electrical hazards\ -Restraints\ -Mercury exposure\ -Biological hazards\ -Falls\ Dangers in Healthcare setting: Never Events or Serious Reportable Events (SREs)\ 1. Causes: inadequate staffing, shortfalls in training, unworkable procedures, etc.\ 2. Examples: Administering the wrong blood, Falls and trauma\ CAUTIs (catheter acquired uti), IV infections, DVTs 1\. Allergies\ -Immune reaction to non-harmful substances\ -Range from minor (sneezing, conjunctivitis) to severe (swelling of the throat, anaphylaxis)\ -Contact: latex, antimicrobials, hygiene products\ -Food/drug: medications, shellfish, iodine, nuts\ -Environmental: mold, dust, pollen\ **[Ask patient about allergies!!! And Check the Chart!]** Allergies cont.\ 1. Prevent when possible\ 2. Check allergies prior to any med or procedure!\ 3. Facilities often use signs -- pay attention\ 4. Pre-treat: Often used for minor reactions to necessary exposure like Iodine allergy with contrast CT scan\ 5. Treat: Steroids, antihistamines, epinephrine\ Watch Vital Signs closely. **[Be prepared for emergency interventions!]** **[Infection control:]** What is Infection? When microorganisms capable of producing disease invade the body. Six Links in the Spread of Infection: A diagram of a chain Description automatically generated 1. Infectious agent\ - Pathogens\ -Normal flora that become pathogenic 2. Reservoir\ -May be living\ -Humans, animals\ -Carriers: not sick, but can infect others\ -May be nonliving\ -Food, surfaces, water\ -Must meet living requirements of the organism\ -Nutrients, moisture, pH, temp, oxygen, light 3. Portal of Exit -Bodily fluids (most common)\ -Coughing, sneezing, diarrhea\ - Seeping wounds\ - Tubes, IV lines 4\. Means/Mode of Transmission -Contact: Direct: physical contact vs Indirect: fomites\ -Droplet: Cough, sneeze\ -Airborne: Via air conditioning, sweeping\ -Vector: mosquito, tick, rabid animal 5\. Portal of entry -Eye, nares, mouth, vagina, cuts, scrapes\ -Wounds, surgical sites, IV or drainage tube sites\ -Bite from a vector 6\. Susceptible host \- Person with inadequate defense\ -Depends on: Organism factors, Virulence: power to cause disease, Favorable environment, Number of organisms \- Host factors: Age- very young and very\ old. Immune system- may be compromised from disease or medications **[Infection Control: Stages of Infection:]**\ 1. Incubation: From time of infection until manifestation of symptoms; can infect\ others.\ 2. Prodromal: Appearance of vague symptoms; not all diseases have this stage.\ 3. Illness: Signs and symptoms present.\ 4. Decline: Number of pathogens decline\ 5. Convalescence: Tissue repair, return to health **[Infection Control: Lines of Defense]**:\ Primary Defenses:\ 1. Normal flora\ - GI, skin, urinary, vaginal\ 2. Anatomical features\ - Intact skin, mucous membranes\ 3. Body defenses\ -Acidic environments, enzymes Secondary Defenses:\ 1. Biochemical processes activated by chemicals released by pathogens -Phagocytosis\ -Complement cascade\ -Inflammation\ -Fever **[Infection Control: Lines of Defense]**\ Tertiary defenses a.k.a. Immunity:\ 1. Cells and antibodies that destroy organisms or toxins\ -Humoral immunity: B-cell production of antibodies in response to an antigen\ -Cell-mediated immunity: Direct destruction of infected cells by T cells\ 2. Can be\ - Natural active: Make antibodies (chicken pox)\ -Artificial active: Medical interference (vaccines)\ -Natural passive: No medical interference (breast milk, mothers antibodies passed)\ -Artificial passive: given antibodies (IGG injections) **[Infection Control: Increased Infection Risk:]** 1. Developmental stage 2. Breaks in the skin 3. Illness/injury, chronic disease 4. Smoking, substance abuse 5. Multiple sex partners 6. Medications that inhibit/decrease immune response 7. Nursing/medical procedures 8. Access to clean water/sanitation 9. Environmental/work factors -Pathogen is spread via air currents\ - Requires specially ventilated rooms (when available) and extra precautions when dealing with linens and cleaning procedures\ - Same as droplet with addition of special masks (N95) or other respirator\ - Doors must remain closed **[Vital Signs:]** **[Variances in Temperature]**\ [Fever (pyrexia):] High body temperature (greater than 100°F or 37.8°C). Occurs in response to pyrogens (e.g., bacteria). Pyrogens induce secretion of substances\ (prostaglandins) that reset the hypothalamic thermostat at a higher temperature.\ [Hyperpyrexia]:\ Abnormally high body temperature; fever greater than 105.8°F (41.0°C).\ [Hypothermia:] Core temperature below normal (less than 95°F or 35°C). Associated with extended exposure to cold (e.g., extreme weather, immersion in cold water, or lack of\ shelter and clothing). **[Pulse:]** Factors That Influence Pulse Rate: - Developmental level - Gender - Exercise - Food intake - Stress - Fever - Disease - Blood loss - Position change - Medication [Common Pulse Points]: - Radial: Laterally on the anterior wrist - Brachial: Medially in the antecubital space - Carotid: Between midline and side of neck. Only by trained professionals for CPR and for assessing circulation to the head. - Temporal: Located on the side of the forehead - Dorsalis pedis: Top of the foot - Femoral: In the groin fold - Popliteal: Behind the knee - Apical: At the apex of the heart - Pulse deficit: Hear a heartbeat but do not feel a beat at a pulse point - Bradycardia: Rate less than 60 bpm - Tachycardia: Rate greater than 100 bpm - Is the rate regular or irregular?\ What is the quality of the pulse?\ Bounding?\ Thready? **[Respiration]**: The exchange of oxygen and carbon dioxide in the body\ **[Two separate processes]**\ [Mechanical:] Pulmonary ventilation; breathing Active movement of air in and out of the respiratory system\ [Chemical]: Exchange of oxygen and carbon dioxide. Transport of oxygen and carbon dioxide throughout the body. Exchange of gases between capillaries and tissues. Rate varies with age, exertion, emotions, and other factors.\ "Normal" is 12-20\* for an adult\ Regulators: Level of carbon dioxide in the blood. Central chemoreceptors, Peripheral chemoreceptors. **[Factors That Influence Respirations:]** - Developmental level - Exercise - Pain - Stress - Smoking - Fever - Hemoglobin **[Variations In Assessment Findings:]** - **[Rate: ]** [-Apnea:] Cessation of Breathing [-Bradypnea:] Abnormally Slow [-Tavhypnea:] Abnormally Fast - **[Depth:]** [-Deep] [-Shallow] [-Normal] **[Variations in Breath Sounds]**:\ Wheeze: High-pitched continuous musical sounds, usually heard on expiration\ Rhonchi: Low-pitched continuous sounds caused by secretions in the large airways\ Crackles: Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds. **[Blood Pressure: ]** [Systolic pressure]: Peak pressure exerted against arterial walls as the ventricles contract and eject blood\ [Diastolic pressure:] Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest Influenced by Cardiac function, Peripheral vascular resistance, Blood volume. **[Factors That Influence Blood Pressure:]** - Developmental stage - Gender - Family history - Lifestyle - Exercise - Body position - Stress - Pain - Race - Obesity - Diurnal variations - Medications - Diseases - Genetic variations Nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of vital signs, vital sign trends, and decisions based on abnormal vital sign findings. **[Physical Assessment:]** The nurse performs a physical examination to:\ ◦ Establish baseline data.\ ◦ Identify nursing diagnoses, collaborative problems, or wellness diagnoses.\ ◦ Monitor the status of an identified problem.\ ◦ Screen for health problems. Promote client comfort:\ ◦ Verbal and Nonverbal communication\ ◦ Develop rapport.\ ◦ Explain the procedure.\ ◦ Respect cultural differences.\ ◦ Use proper positioning Three major skills used:\ 1. Inspection\ 2. Auscultation\ 3. Palpation **[Inspection]**: Use of sight to gather data\ Used throughout physical examination\ Tools to enhance inspection\ ◦ Otoscope\ ◦ Ophthalmoscope\ ◦ Penlight\ Examples: Skin color, gait,\ general appearance, behavior **[Palpation]**: Use of touch to gather data\ Begins with light pressure, moving to deep palpation\ ◦ Caution with use of deep palpation\ Parts of the hands used\ ◦ Fingertips: Tactile discrimination\ ◦ Dorsum: Temperature determination\ ◦ Palm: General area of pulsation\ ◦ Grasping (fingers and thumb): Mass evaluation\ Examples: Edema, moisture, anatomical\ landmarks, masses. **[Auscultation]**: Use of hearing to gather assessment data\ Direct auscultation\ ◦ Listening without an instrument\ Indirect auscultation\ ◦ Use of a stethoscope to listen\ ◦ Diaphragm: High-pitched sounds\ ◦ Bell: Low-pitched sounds\ Examples: Heart sounds, lung sounds **[Components of A Head- to-Toe Assessment:]**\ Head, Ears, Eyes, Nose and Throat (HEENT)\ Neurological -- brain and reflexes\ Integumentary - Skin and nails\ Circulatory -- heart and blood vessels\ Respiratory -- lungs, breathing, oxygenation\ Abdominal - digestion, bowel sounds\ Genitourinary --urinary elimination, reproductive organs\ Musculoskeletal -- range of motion, balance, coordination Use good communication skills, be respectful, build rapport. A focused assessment is used to assess a particular area of concern.\ At the bedside always include orientation, heart, lungs and abdomen in your focused assessment.\ **[Perform in this order: inspect, auscultate, palpate\ Document all clinical findings\ Alert the physician of any new or worsening abnormal\ findings.]** **[Basics of Med Admin:]**\ [Food and Drug Administration (FDA) regulates:]\ -Manufacture and sale of all medications and monitors their safety and effectiveness\ -Testing of any medication that is to be marketed and sold in the United States\ -Setting official drug standards\ -Determination of prescription vs OTC designation\ -Labeling requirements for medications\ -Pregnancy, lactation and females\ -Pediatrics Controlled Substances\ -Uncontrolled Substances: Require monitoring but pose little risk of misuse or addiction like Antibiotics, cholesterol-lowering medications, etc.\ -Controlled Substances: Carry a risk for misuse and/or dependence. Schedule I-V\ depending on risk. Controlled Substances\ **[Schedule I]**:\ υ no current medical use, high abuse potential\ υ heroin, LSD, ecstasy, bath salts, marijuana\ **[Schedule II]**\ υ highly addictive, high abuse potential\ υ some accepted medical uses\ υ methadone, oxycodone, fentanyl, morphine, codeine\ **[Schedule III]**\ υ low to moderate potential for dependence and abuse\ υ suboxone, ketamine, anabolic steroids\ **[Schedule IV]**\ υ low probability of misuse and abuse\ υ alprazolam, clonazepam, diazepam, lorazepam, carisoprodol\ **[Schedule V]**\ υ very low potential for misuse\ υ Robitussin, ezogabine **[Medication Reconciliation:]**\ υ Formal process for creating a complete, accurate list of a patient's medications\ υ Compare current medications with the patient's records and medication orders\ υ Goal is to reduce omissions, duplications, dosing errors and medication interactions\ υ Completed at each transition of care **[5 step process]**\ υ Generate a list of meds the patient is currently taking\ υ Develop a list of the meds that will be prescribed under the current treatment plan\ υ Compare the lists\ υ Make clinical decisions based on the comparison\ υ Communicate the new list to caregivers and to the patient **[Pharmacological Considerations:]**\ υ Pharmacokinetics\ - Movement of a drug through the body\ -Consists of four components\ \*Absorption\ \*Distribution\ \*Metabolism\ \*Excretion\ υ Pharmacodynamics\ -How the drug impacts the body\ -The primary and secondary effects of the drug\ -Covered more in later semesters **[Absorption]**:\ υ Movement of drug from the site of administration into the bloodstream\ υ Rate of absorption determines when the medication is available\ υ Factors affecting absorption\ **[υ Route of administration]**\ υ Oral, inhalant, parenteral, etc.\ υ Different routes have different speeds of absorption\ **[υ Drug solubility]**\ υ Enteric-coated can't be absorbed in the stomach\ υ Timed-release dissolve slowly\ **[υ pH/ionization]**\ υ Acidic medicines absorb better in the stomach\ υ Basic/alkaline medicines absorb better in the intestines\ υ Ionized molecules are lipid insoluble and can't pass through the\ cell membrane\ **[υ Blood flow]**\ υ Greater blood flow=faster absorption **[Distribution]**:\ υ Drug transport to tissues and organs through bodily fluids (usually blood)\ υ **[Factors affecting distribution]**\ υ Local blood flow\ υ Membrane permeability\ υ Different organs have\ different levels of capillary permeability\ υ Blood-brain barrier allows very few substances to pass\ **[υ Protein-binding capacity]**\ υ Some drugs bind to proteins and are unavailable\ υ Protein levels can impact distribution and availability of medications **[Metabolism]**\ υ Biotransformation: Chemical conversion of drug into an inactive form\ υ Makes molecules more water soluble for excretion\ υ Mainly in the liver\ υ Other sites: kidneys, plasma, intestines, lungs\ υ Factors affecting metabolism\ υ Liver function\ υ Poor function can lead to toxic drug levels\ υ Health/disease status\ υ Cirrhosis\ υ Inherited metabolic disorders\ υ First-pass effect\ υ Oral meds go to the liver before reaching the body\ υ Many molecules are inactivated\ υ Oral medications are formulated with higher concentrations **[Excretion]**:\ υ Molecules are eliminated from the body\ υ May be completely, partially, or unmetabolized\ υ Several common areas\ υ Kidneys\ υ Liver\ υ GI tract\ υ Lungs\ υ Exocrine glands (sweat glands, tears, etc.) **[Medication- focused Assessment:]**\ υ Before\ υ During\ υ After\ υ Medication history\ υ Allergies\ υ Pregnancy/lactation\ υ Physical examination\ υ Swallowing\ υ Vision\ υ Cognition **[Six Rights of Med Administration]**:\ υ Six rights\ υ Right drug\ υ Right dose\ υ Right time\ υ Right route\ υ Right patient\ υ Right documentation\ **[Other rights]**\ υ Right reason\ υ Right to know\ υ Right to refuse **[Parenteral Medications]**:\ υ Parenteral (around the gut) medications\ υ **[Intradermal: into the skin layers]**\ υ Allergy and TB testing\ υ **[Subcutaneous: into (below) the subcutaneous tissue]**\ υ Slow absorption\ υ Insulin and heparin\ υ **[Intramuscular: into the muscle]**\ υ Fast absorption (large blood supply)\ υ Allows large amounts\ υ Most vaccinations\ υ **[Intravenous: into the vein]**\ υ Instant absorption\ υ "no going back"\ υ Many in-patient meds **[BIG Takeaways!!!!!]**\ υ Medication administration (and medication errors) is one of the main ways we can help or harm our patients\ υ In some areas of nursing, medication administration is your primary responsibility\ υ Take the time to give meds the right way! **[The Nursing Process:]** **[What Is Critical Thinking?]**\ υ A combination of\ - Reasoned thinking\ -Openness to alternatives\ -Ability to reflect\ -A desire to seek truth\ υ Critical thinking is linked to evidence-based practice.\ υ Critical thinking requires recognizing (and challenging) your assumptions **[Assessment]**:\ υ **[1st step of nursing process]**:\ υ Collecting data\ υ Using a systematic and ongoing process\ υ Categorizing data: physical, mental, spiritual, cultural etc..\ υ Recording data **[Subjective]**\ What the patient says (the patient's experience)\ **[Objective]**\ What can be observed or measured\ **[Primary]**\ Obtained directly from the client\ **[Secondary]**\ Obtained secondhand through the medical record or another person **[Nursing Diagnosis]**\ υ Statement of a health problem or issue that the nurse identifies, prevents, or treats independently\ υ Written in terms of human response\ υ NANDA-I officially defined nursing diagnosis\ υ "A clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes" Example: -Pneumonia\ υ Ineffective airway clearance\ υ Impaired gas exchange\ υ Ineffective breathing pattern\ -Broken Leg\ υ Acute pain\ υ Impaired physical mobility\ υ Risk for infection **[Collaborative Problems]**\ υ Physiological complications of diseases, medical treatments, or diagnostic studies\ υ Clients with certain diseases or treatments are at risk for developing the same\ complications.\ υ Always a potential problem, once it becomes actual it is a medical diagnosis\ υ If the nurse can prevent the complication with independent nursing interventions, it\ is NOT a collaborative problem Maslow's Hierarchy of Needs\ υ Often used to prioritize nursing **[Planning starts with goal- setting]**\ υ Goals should be set from the beginning to establish the desired outcomes of care\ υ Goals are based on the Nursing Diagnoses\ υ Goals may also be derived from nursing quality indicators (standards of care)\ υ Involve the patient in setting goals for their care\ υ Goals should be written in terms of the patient perspective\ υ "The patient will be able to..." **[Evaluating the plan]**\ Variables that can alter the effectiveness of an\ intervention to produce the desired outcome:\ The client's ability and motivation to follow treatment\ Availability and support from significant others\ Treatments and therapies performed by other healthcare team members\ Client failure to provide complete information during assessment\ Client's lack of experience, knowledge, or ability\ Staffing in the institution\ Nurse's physical and mental well-being **[Spirit of inquiry and informatics:]** INFORMATICS AND NURSING PRACTICE:\ Facilitates evidence-based practice\ New model of decision making\ "providing holistic, quality care based on the most up- to-date research and knowledge" \~ANA ADVANTAGES OF TECHNOLOGY:\ Increase efficiency, productivity\ Enhance communication\ Track patients and equipment.\ Manage staffing and workflow.\ Reduce errors.\ Commission v. Omission\ Planning v. Execution\ Aid patients with self-care.\ Educate nurses. TECHNOLOGY TOOLS IN HEALTH CARE: EHR and EMAR GPS Tracking of Patients and equipment Bed alarms, other monitors and alert systems Hands free communication devices Barcode scanners Databases to research medications/conditions UptoDate, Medscape Apps used in diagnosing/prescribing Medscape, Epocrates DOCUMENTING IN THE HER: HITECH Act requires EHR for full Medicaid/Medicare reimbursement. Some exceptions: Private practitioners who are opposed, some nursing homes, and state mental hospitals continue to use paper charts. Clinical Facilities rarely allow students to document in the EHR. Schools are using Simulation programs to give students experience with documentation. **[DOCUMENTATION]**: Each facility has their own system for documentation. Some examples of EHR systems: EPIC, Meditech Contain dropdown check lists to speed charting Some common charting formats for notes are: Problem-focused Charting Charting by exception SOAP -- subjective, objective, assessment, plan DAR -- data, action, response PIE -- problem, intervention, evaluate ANA Charting Guidelines: Accurate, valid, and complete; Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; Dated and time-stamped by the persons who created the entry; Legible/readable; and Made using standardized terminology, including acronyms and symbols. **[CHARTING TIPS:]** Timing: Follow agency policy. Document the time of the observation. Most use military time. Block charting: Avoid. Chart a specific time of the note instead of having one big note that spans the entire shift. Never document something before you do it! Format: Per agency (SOAP\< DAR\