LIVE LAB NURSING EHR

Hospital Documentation Practice
SIMULATION
Training environment
Student: Simulated Patient: Encounter: Not StartedAllergies: Simulation

Assigned Patient

Select the simulated hospital patient assigned for this encounter. Admission information, provider orders, and laboratory results will load into the chart.

Start Encounter




Patient Overview / Brain

Documentation Timeline

No documentation filed.

Admission Intake

Complete the simulated admission assessment using only information provided in the scenario or obtained during the student interview.

Admission Information

Chief Complaint & History

Admission Screening

Labs & Orders

Review provider orders and simulated results before documenting care.
OrderTypeFrequency / TimeStatusStudent Review

Laboratory Results

Instructor-entered or scenario-provided simulated laboratory data.
TestResultUnitsReference / Scenario RangeFlagReviewed

Vital Signs

Hospital-style flowsheet

Head-to-Toe Assessment

Document WDL only when you actually assessed that body system. Select Exception to enter focused findings.

Pain Assessment & Reassessment

Lines / Drains / Airways

Simulation documentation
DeviceLocationSize/GaugeSiteStatusComments

Medication Administration Record

SIMULATION ONLY — no medication is actually administered.
MedicationDoseRouteDuePre-Administration CheckStatusReason / Follow-Up

I&O Flowsheet

TimeTypeSourcemLComments

Nursing Progress Note



Filed Notes

No notes filed.

Nursing Care Plan

SBAR / Handoff





Discharge Documentation

Simulation discharge workflow. Students should document teaching and final status rather than simply checking every item.

Discharge Assessment

Discharge Teaching

Instructor Review

Reviews completion and follow-up habits without supplying clinical answers.

Sign & Close Encounter