Guided Notes
Clinical Documentation in the EHR
Notes, templates and smart text, flowsheets for structured data, nursing documentation, signing and co-signing, and the balance between structured and narrative data.
Types of clinical documentation
Slide 1 / 5• Provider notes: H&P, progress notes, consults, procedure notes, discharge summaries, office visit notes. • Nursing documentation: admission assessment, shift assessments, care plans, education, I&O (intake/output). • Flowsheets: rows of structured data over time (vitals, pain, neuro checks, lines/drains/airways). • Questionnaires and forms: screening tools (depression PHQ-9, fall risk, sepsis screening). • Scanned documents: outside records, consent forms.