Nursing Documentation and SBAR Communication Study Guide.
1. What are the Primary purpose of nursing doc- Provide evidence that practice stan-
umentation? dards have been upheld
Communicate with other health-care
providers
Ensure the best, most seamless
health-care is provided
2. Documentation must be these 6 things Timely
Legible
Concise
Accurate
Complete
Logically organized
3. Concise documentation means that that it is Brief
Incomplete sentences
Eliminate words that do not change the
meaning of the sentence
No need to state "patient" - who else
would it be?
4. this is an example of a nurse note Experienced dyspnea ambulating in
hall. Returned to bed via WC. RR and
ettort WNL w/i 5 min
5. Accurate documentation means that that it is Every entry in a medical record re-
quires:
Date
1/5
, Nursing Documentation and SBAR Communication Study Guide.
Time (24-hour clock)
Signature or Initials
6. this is an example of how you sign your Your credentials ALWAYS accompany
name your signature
Nancy Nice RN
MaryLou Who SN, GBCN
7. What is the appropriate signature? MaryLou Who SN, GBCN
8. what type of documentation is PIE? Problem-focused documentation
9. what does PIE stand for? Problem
Intervention
Evaluate
10. For PIE, what should be included for problem? Describe the problem
Include abnormal assessment data
11. For PIE, what should be included for interven- Describe what was done to alleviate the
tion? problem
What is your plan
What did you do to maintain the prob-
lem so that it does not get worse
12. For PIE, what should be included for evaluate? Describe the patient response to the
nursing interventions that were done
Was the treatment ettective
2/5
1. What are the Primary purpose of nursing doc- Provide evidence that practice stan-
umentation? dards have been upheld
Communicate with other health-care
providers
Ensure the best, most seamless
health-care is provided
2. Documentation must be these 6 things Timely
Legible
Concise
Accurate
Complete
Logically organized
3. Concise documentation means that that it is Brief
Incomplete sentences
Eliminate words that do not change the
meaning of the sentence
No need to state "patient" - who else
would it be?
4. this is an example of a nurse note Experienced dyspnea ambulating in
hall. Returned to bed via WC. RR and
ettort WNL w/i 5 min
5. Accurate documentation means that that it is Every entry in a medical record re-
quires:
Date
1/5
, Nursing Documentation and SBAR Communication Study Guide.
Time (24-hour clock)
Signature or Initials
6. this is an example of how you sign your Your credentials ALWAYS accompany
name your signature
Nancy Nice RN
MaryLou Who SN, GBCN
7. What is the appropriate signature? MaryLou Who SN, GBCN
8. what type of documentation is PIE? Problem-focused documentation
9. what does PIE stand for? Problem
Intervention
Evaluate
10. For PIE, what should be included for problem? Describe the problem
Include abnormal assessment data
11. For PIE, what should be included for interven- Describe what was done to alleviate the
tion? problem
What is your plan
What did you do to maintain the prob-
lem so that it does not get worse
12. For PIE, what should be included for evaluate? Describe the patient response to the
nursing interventions that were done
Was the treatment ettective
2/5
