Beyond the Bedside Chapter 20 — Documenting & Reporting
Not charted, not done—unless you chart like a pro. In this power episode, we turn documentation and reporting into a clinical superpower: clear, timely, HIPAA-safe, and legally rock solid.
What you’ll master
The big five: POMR/SOAP, PIE/PIER, Focus (DAR), CBE, and collaborative pathways
ISBARR that actually gets action (with read-backs done right)
HIPAA essentials + ISMP/JCAHO “Do Not Use” abbreviation traps
Purposeful rounding (the 4 Ps + the key phrase that boosts satisfaction and safety)
Full case studies (start-to-finish)
Phillippe — post-colonoscopy discharge teaching that sticks
Millie — post-op wound infection, variance charting, and WOC consults
Jason — minor in custody, legal/ethical tightrope, and bulletproof ISBARR
NCLEX angles woven in: best documentation statements, where trends live (graphic record), PRN timing, verbal-order limits, and privacy pitfalls.
Hit play to chart like a scientist, hand off like a pilot, and protect privacy like a vault.
Follow the show, drop a review, and share with your study group—mastery loves company.
