Nursing Fundamentals: Documentation Essentials and Shift Communication for Continuity of Care

Why Documentation and Handoff Matter (Workflow Mindset)

Think of documentation and shift communication as one continuous workflow: assess → document → act → document → reassess → document → hand off. Your charting creates the legal and clinical record of what was observed and done; your handoff turns that record into a prioritized plan for the next nurse. Continuity of care improves when notes are timely, objective, and clearly connect assessment findings to interventions and outcomes.

Two practical rules

• If it wasn’t charted, it wasn’t done (from a legal/quality standpoint).
• Chart for the next clinician: write so someone who has never met the patient can safely continue care.

Core Documentation Principles (How to Write Like a Clinician)

1) Objective, specific language

Document what you see, hear, measure, and do—avoid labels and assumptions.

• Avoid: “Patient is rude,” “noncompliant,” “doing fine,” “appears drunk.”
• Prefer: “Patient raised voice, stated ‘Leave me alone,’ refused 0900 meds after education provided,” “gait unsteady, odor of alcohol noted on breath, speech slurred.”

2) Timeliness and sequencing

Chart as close to real time as possible. When you must chart late, follow facility policy and clearly indicate the actual time of care vs. time of entry (e.g., “Late entry for 1430…”). In narrative notes, keep the sequence clear: finding → action → response → follow-up plan.

3) Use patient quotes when relevant

Quotes are helpful for symptoms, refusals, education understanding, and safety concerns.

• “Patient states, ‘My chest feels tight when I walk to the bathroom.’”
• “Patient states, ‘I don’t want that shot,’ declines after risks/benefits explained.”

4) Charting by exception (CBE) concepts (if used on your unit)

Some units chart normal findings via checkboxes/flowsheets and require narrative only for exceptions. If your unit uses CBE, you still must chart:

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• Abnormal findings (what, where, severity, associated symptoms).
• Actions taken (interventions, notifications, orders received).
• Patient response (reassessment data, tolerance, outcomes).
• Safety measures (precautions initiated, equipment in place).

5) Link assessment → intervention → reassessment (AIR loop)

High-quality notes show clinical reasoning without long paragraphs. Use an “AIR loop” every time you address a problem:

• Assessment: what you found (data).
• Intervention: what you did (and who you notified).
• Reassessment: what changed (data) and next steps.

Example (pain): “Pain 8/10 R hip with movement. Administered PRN med per MAR and repositioned with pillow support. Reassess 45 min later: pain 3/10 at rest, 5/10 with turning; patient states ‘much better.’”

Required Elements to Capture for Common Bedside Tasks

The items below are frequently audited and often missed. Use them as a mental checklist for flowsheets and brief narrative notes.

Vital signs (with context)

• Values and method/site as required by your system (e.g., oral temp, manual BP).
• Context: rest vs. activity, pain, anxiety, fever interventions, oxygen use, recent meds, position.
• Trends/abnormal response: what you did and who you notified.

Charting tip: If a value is abnormal, document a repeat (when appropriate) and the clinical action taken.

Pain assessment and reassessment

• Score (scale used), location, quality, onset, aggravating/relieving factors, functional impact.
• Interventions (med and non-med), education, safety checks (e.g., sedation risk if applicable).
• Reassessment time and result (objective and patient-reported).

Hygiene/skin findings

• Care provided (bath type, oral care, peri care, linen change).
• Skin assessment: color, temperature, moisture, integrity, pressure areas, wounds/dressings (as applicable).
• Abnormal findings: location, size, appearance, drainage/odor, pain, surrounding skin.
• Actions: barrier cream, turning schedule, wound care per orders, consults/notifications.

Mobility level and fall precautions

• Current mobility status (independent/assist level, device used, gait quality).
• Safety measures in place (bed low/locked, call light, non-skid socks, alarms if ordered, clutter-free path).
• Response/tolerance to activity and any symptoms (dizziness, SOB, pain).
• Education provided (use call light, ask for help) and patient understanding.

Intake & output totals

• What counts and what doesn’t per unit policy (oral, IV, tube feeds; urine, emesis, drains).
• Shift totals and notable changes (low urine output, concentrated urine, large emesis).
• Actions: encourage fluids if appropriate, bladder scan per protocol, notify provider per parameters.

Oxygen device and response

• Device type and flow/FiO2, humidification if used, patient tolerance.
• SpO2 and respiratory assessment context (rest/activity), positioning.
• Interventions: titration per order/protocol, incentive spirometry coaching if applicable, notify RT/provider.
• Response: updated SpO2, work of breathing, patient-reported relief.

Specimen collection details

• Specimen type and source, collection method, time collected.
• Labeling/transport details per policy (at bedside, on ice, to lab immediately).
• Patient prep if relevant (clean-catch teaching, fasting status if applicable).
• Any issues: insufficient volume, contamination risk, delays and actions taken.

Patient education

• Topic taught (meds, mobility safety, oxygen use, wound care, diet, device care).
• Method: verbal, demonstration, teach-back, written materials.
• Patient response/understanding: teach-back results, questions, barriers (language, pain, cognition).
• Follow-up plan: reinforce later, involve family, request interpreter, notify provider if refusal affects safety.

Templates: Concise Narrative Notes (Copy-and-Adapt)

Use these templates to stay brief while still meeting clinical and legal expectations. Replace bracketed text with specifics.

1) Focus note using AIR loop

[Time] Assessment: [objective finding + patient quote if relevant].  Intervention: [what you did, orders followed, who notified].  Reassessment: [objective result + patient report].  Plan: [next step/monitoring].

2) Abnormal vital signs with actions

[Time] VS: BP [ ], HR [ ], RR [ ], T [ ], SpO2 [ ] on [device/flow]. Patient [resting/after ambulation], reports [symptoms/denies]. Rechecked BP [time] with [manual/appropriate cuff]. Implemented [positioning/fluids per order/med per MAR]. Notified [provider/charge/RT] at [time]; received order to [ ]. Will continue to monitor q[ ].

3) Pain intervention and reassessment

[Time] Patient reports pain [score]/10 at [location], describes as [quality]. Given [intervention(s)] per [order/MAR]. Safety: [side rails per policy, call light within reach]. Reassess at [time]: pain [score]/10, patient states “[quote].” Tolerating [activity/rest].

4) Skin/hygiene exception note

[Time] Hygiene provided: [bath/oral/peri/linen]. Skin: [normal findings]. Exception: [location] with [description: size, color, drainage, odor, surrounding skin, pain]. Implemented [barrier/turning/offloading/dressing per order]. Notified [wound nurse/provider] at [time] and documented per wound protocol.

5) Mobility/fall safety note

[Time] Mobility: [independent/assist x1/x2] with [walker/gait belt]. Ambulated [distance] to [location]. Tolerance: [steady/unsteady], denies/endorses [dizziness/SOB/pain]. Fall precautions: [bed low/locked, call light, non-skid, alarm if ordered]. Education: instructed to call for assist; patient verbalized understanding.

6) Oxygen change and response

[Time] SpO2 [ ]% on [device/flow]. Increased/decreased to [ ] per [order/protocol] due to [finding]. Positioned [HOB elevated]. Reassess at [time]: SpO2 [ ]%, WOB [improved/unchanged], patient states “[quote].” RT/provider notified [if applicable].

7) Specimen collection note

[Time] Collected [specimen] via [method/source] after teaching [key steps]. Labeled at bedside and sent to lab at [time] via [tube system/courier]. Specimen appearance: [if relevant]. No complications.

8) Patient education note (teach-back)

[Time] Education provided on [topic]. Method: [verbal/demo/teach-back/materials]. Patient/family response: [teach-back accurate/needs reinforcement], questions addressed. Barrier(s): [pain/hearing/language]; [interpreter used]. Plan to reinforce at [time] and notify [team member] if needed.

Templates: Flowsheet Entries (What “Complete” Looks Like)

Flowsheets vary by EHR, but completeness usually means documenting the measurement plus the context and any action. Use the examples to guide what to include in the comment fields.

How to Document Abnormal Findings and Escalation (Action-Oriented Charting)

Use a “What/So what/Now what” micro-structure

• What: abnormal data (numbers, appearance, behavior) + context.
• So what: patient impact (symptoms, functional change) without diagnosing.
• Now what: interventions, notifications, orders, reassessment.

Document notifications clearly

When you notify someone, chart: who you notified, when, what you reported, and what you were told to do.

Notified Dr. Patel at 1610 of BP 88/54 with dizziness on standing and UOP 150 mL this shift. Order received: 500 mL LR bolus now; repeat BP q15 min x1 hr; notify if SBP <90 persists.

Refusals: chart education + patient decision + safety plan

Refusals are common charting pitfalls. Avoid arguing in the chart; document the facts.

Patient declined CHG bath despite education on infection prevention; states “I’m too tired.” Offered partial bath and oral care; patient accepted oral care only. Will re-offer at 2100. Call light within reach.

Shift Report as a Repeatable Workflow (Bedside Handoff)

Handoff should be prioritized, safety-focused, and actionable. Use a consistent structure so nothing critical gets missed, especially when the unit is busy.

Recommended structure: “One-minute headline, then systems and tasks”

• Headline (prioritized summary): who the patient is, why they’re here, current stability, and what could go wrong this shift.
• Safety concerns: fall risk, aspiration risk, isolation, behavior concerns, alarms, code status per policy.
• Lines/tubes/drains: what is present, where, and any issues (patency, site condition, output concerns).
• Respiratory/oxygen: device/flow and typical SpO2 range; recent changes and response.
• Pain/comfort: what works, last intervention, reassessment status.
• Mobility: assist level, device, tolerance, precautions.
• I&O highlights: totals, concerning trends, drains output if applicable.
• Skin/wounds: key findings, dressing schedule, turning plan.
• Pending labs/tests/consults: what is pending and what to do with results.
• Patient goals for the shift: measurable and patient-centered (e.g., “walk to chair x2,” “pain ≤4/10,” “maintain SpO2 ≥92% on 2 L”).

Bedside handoff: what to verify in the room

• Patient ID per policy; introduce oncoming nurse.
• Safety scan: bed low/locked, call light, fall precautions, oxygen setup, suction if needed.
• Lines/tubes/drains: trace from patient to source; check labeling and settings per policy.
• Skin check as appropriate and permitted; confirm dressing status and schedule.
• Clarify patient questions and immediate needs (pain, toileting, positioning).

Shift report mini-template (spoken)

Room __, [Name/age]. Here for [reason]. Today: [stability + key events]. Biggest risks: [top 1–2]. Safety: [falls/isolation/code status per policy]. Lines/tubes/drains: [what/where/any issues]. Resp: [O2 device/flow, baseline SpO2, changes]. Pain: [location/what works/last med + reassess]. Mobility: [assist level/device]. Skin: [key findings/dressings/turn plan]. I&O: [totals/highlights]. Pending: [labs/tests/consults] and what to watch for. Goals: [1–3 goals].

Chart Review Exercises (Practice Finding Gaps and Fixing Wording)

Exercise 1: Identify missing documentation

Chart snippet: “0900 VS taken. Pain med given. Patient up to chair. UA sent.”

Find at least 8 missing elements:

• Actual VS values and context (rest/activity, oxygen device).
• Pain score before intervention; location/quality.
• Name/dose/route of pain med belongs in MAR, but note should link to effect.
• Reassessment time and pain score after intervention.
• Mobility assist level/device and tolerance (dizziness/SOB/pain).
• Fall precautions in place during/after transfer.
• UA collection method/time and labeling/transport details.
• Any abnormal findings and actions/notifications.

Exercise 2: Correct ambiguous or subjective wording

Rewrite each statement to be objective and clinically useful.

• Ambiguous: “Patient doing better.” Rewrite: “Patient reports nausea decreased from 7/10 to 2/10; tolerated 50% of lunch; no emesis since 1200.”
• Subjective label: “Noncompliant with oxygen.” Rewrite: “Patient removed nasal cannula twice; states ‘It dries my nose.’ Education provided; humidification applied per setup; patient agreed to wear; SpO2 94% on 2 L.”
• Vague: “Skin looks bad.” Rewrite: “Sacral area with 2 cm nonblanchable erythema, skin intact, warm, tender 3/10; offloaded and barrier applied.”
• Assumption: “Patient intoxicated.” Rewrite: “Speech slurred, unsteady gait, odor of alcohol on breath; oriented x2; denies drinking today.”

Exercise 3: Link assessment-intervention-reassessment (fill in the blanks)

Scenario: 1400 SpO2 88% on room air after ambulating to bathroom; patient reports shortness of breath.

Your note should include:

• Assessment: SpO2, device, activity context, respiratory effort, patient quote.
• Intervention: positioning, oxygen initiation/titration per order/protocol, coaching, notification if indicated.
• Reassessment: time, new SpO2, symptoms, tolerance.

[Time] Assessment: ________________________________  Intervention: ________________________________  Reassessment: ________________________________

Exercise 4: Bedside handoff practice (prioritize and keep it short)

Scenario data: Patient admitted for pneumonia. On 2 L NC, baseline SpO2 92–94%. Fall risk high; unsteady when rushing to bathroom. IV in L forearm, patent. Urine output low this shift. Pain 6/10 with coughing; PRN given with good effect. Skin: redness to sacrum, intact; turning q2h. Pending: morning CBC, chest x-ray result not yet posted. Goal: ambulate to chair for meals, maintain SpO2 ≥92%.

Task: Give a 45–60 second report using the mini-template. Ensure you include: safety concerns, oxygen status, mobility level, I&O concern, skin plan, and pending items.