Introduction to Nursing Documentation in eStar
If you're not a nurse, it can be hard to grasp just how much of a nurse's job revolves around documentation--and how different that documentation is from what physicians or other clinicians do. Nurses are constantly observing, planning, acting, and communication--all while keeping meticulous records. These records aren't just paperwork--they're critical tools for safety, communication, and care continuity.
In this short series, we will give you an overview of some basic, inpatient-focused nursing documentation activities. While this demonstration will give some introduction to nursing documentation, there are many unique workflows and documentation systems in Epic depending on setting, including (but not limited to) outpatient, labor and delivery, perioperative, and emergency department.
*It is recommended you have a basic understanding of Epic prior to watching this series as basic concepts will not be explained. The VCLIC "Intro to Epic for Non-Clinicians" is a great introduction.
The "Brain" and the "List" -- Assigning Patients and Basic Tasks
Once a nurse starts a shift, the first step is understanding which patients they're responsible for--and what those patients need over the next shift. That's where two key Epic tools come in: the Patient List and the Brain.
Think of the Patient List as the nurse's roster--a bird's eye view of who's on their assignment, with quick-glance clinical data. The Brain, on the other hand, is like a dynamic to-do list that builds on the traditional patient list. It pulls in tasks, medications, documentation prompts, and helps nurses stay on track throughout the day.
These tools are central to managing care in real time--they support not just individual workflow, but also safety, prioritization, and communication across the team.
Medication Administration
Medication administration is one of the most high-risk, high-frequency tasks nurses perform--and it's tightly integrated into both documentation and clinical workflow.
Unlike order entry, which happens once, giving medications is a hands-on, repeated process that requires precise timing, patient verification, safety checks, and real-time documentation. Nurses often administer dozens of medications per shift, many of which have critical safety implications.
In Epic, this process is supported by Barcode Medication Administration, or BCMA, which ensures the right patient gets the right drug at the right time. But there's more to it than just scanning--timing, clinical judgement, and communication all come into play. Let's walk through how nurses carry out this essential task.
Flowsheet Documentation
Flowsheets are the backbone of nursing documentation in Epic. If you imagine a nurse's day as a nonstop cycle of assessing, intervening, and reassessing--flowsheets are where all of this gets recorded.
Unlike narrative notes and most notes created by our physician colleagues, flowsheets use structured rows and columns to track vital signs, assessments, interventions, and responses over time. This format makes it easier to see patterns, identify changes in patient condition, and support team-based care.
For nurses, documenting in flowsheets is continuous. We're entering data as we go--not just to check a box, but to create a shared, real-time clinical picture that other clinicians can rely on. Let's look at how these flowsheets are organized and what kind of information they capture.
Notes, Communication, Handoff, and Closing Thoughts
While flowsheets rein king in nursing documentation, there are still important facets in narrative documentation and opportunities to communicate via the electronic health record. Here, we will discuss nurse narratives documentation and wrap up the series.