Digital Documentation Mentoring Tips

Digital Documentation Mentoring Tips

This page is a shared resource for frontline healthcare workers including PSWs and nurses learning to document care digitally in long-term care settings. Use it to collect short, practical tips that help new team members document clearly, safely, and confidently.

How to use this page

• Add one short tip at a time (1–2 sentences).
• Focus on general practice, not real residents or workplaces.
• Do not include names, room numbers, or any identifying details.
• Optional: add your initials in brackets at the end of your tip (for example, [AB]).

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1. Accurate and Timely Entries

Example tips (keep your own tips this short):

• Before charting, double-check that you are in the correct resident profile and shift.
• Document important changes as soon as possible after care, not at the end of the day.

Add your tips below:

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2. Using SBAR in Digital Notes

Example tips:

• Use SBAR headings or structure in your note (Situation, Background, Assessment, Recommendation) to keep information organized.
• In the Situation, write one clear sentence about what changed and why you are documenting it now.

Add your tips below:

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3. Preventing and Fixing Common Entry Errors

Example tips:

• If you notice a mistake after saving a note, follow your site’s process to correct it (for example, add an addendum instead of deleting the entry).
• If the system freezes or logs you out, re-check that your last note was saved before moving on.

Add your tips below:

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4. Safe Team Communication and Shift Changes

Example tips:

• In shift-change notes, highlight only the most important changes since the last shift (mobility, pain, mood, eating, safety).
• Use objective language (what you saw, heard, or measured) instead of personal opinions or assumptions.

Add your tips below:

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5. Privacy, Confidentiality, and Respect

Example tips:

• Never copy sensitive details into group chats or personal devices; keep documentation inside approved systems only.
• Avoid using labels or judgmental language in notes; describe behaviours respectfully and factually.

Add your tips below:

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6. Optional Reflection (Not Assessed)

In your own notes or Portfolio Companion, you may wish to record:

• One mentoring tip from this page you plan to use in your practice.
• One area of digital documentation you still want to improve.