Objective
Focus on observable findings, patient statements and actions taken.
Interactive nurse education · Pilot
What should you
document next?
Choose a common nursing event. Complete a three-minute check. See which documentation elements may still need attention.
No patient information requested.
DOCUMENTATION DECISION LAB01—05
03
EVENT PATHWAY
Patient fell.
Does the record show the complete clinical response?
Step 1 of 3
What happened during the shift?
Select one event. The questions will adjust to the situation.
Use this tool with fictional or deidentified scenarios only. Do not enter patient identifiers or protected health information.
Built for the realities of nursing
Read less.
Practice the sequence.
Strong documentation makes the clinical timeline understandable. The Decision Lab helps nurses rehearse the elements that connect assessment, communication, intervention and follow-up.
Specific
Identify who, what, when, the response received and what happened next.
Closed loop
Connect the assessment to communication, intervention and reassessment.
Evidence notes