If you’re a travel nurse starting your first assignment, the thought of documentation may be daunting. After all, every facility has their own specific charting requirements. But don’t worry – we’ve got you covered! In this blog post, we’ll go over the basics of nursing documentation. You’ll learn what information you need to document on every patient, during every shift. By following these guidelines, you’ll be able to confidently chart your patients’ care and avoid any penalties from your facility or staffing agency.

Chartnote was created with the clinician in mind. We know that you are busy and need a way to take better notes without having to sacrifice your time with patients. Chartnote is an electronic medical record (EMR) companion that allows you to do just that! With Chartnote, you can easily document patient encounters with a few clicks or dictate your note using next-generation AI voice recognition.

How can I be sure I’m not the next nurse to face criminal charges for a mistake? Medication-related errors are the most common mistake made by nurses. Forming solid documentation habits can provide a framework nurses can use to defend your nursing judgment and interventions