The Texas Nursing Practice Act (NPA) helps protect the public. It authorizes the Texas Board of Nursing (BON) to regulate nursing practices to ensure public safety and the provision of high-quality patient care. Nurses should be familiar with the state regulations and standards of nursing practice. They play an essential role as a primary point of contact for the healthcare team and the patients in coordinating all aspects of patient care delivery. Nurses are responsible for communicating with the healthcare members and others involved in care, for example, through nursing documentation (Coleman et al., 2023). Nursing documentation or charting should include the most critical components as they are crucial in managing patient care. These components make up the acronym FACT:

• Factual
• Accurate
• Complete
• Timely

If the nurse fails to document the crucial components of nursing documentation, it would be difficult to follow up on the patient treatment plan or process (Tajabadi et al., 2020). Similarly, if the assessment or medication is not timely, the providers would not have accurate information about the patient's clinical condition, which may lead to delays in treatment and poor outcomes. Nurses can protect their patients and licenses by ensuring their nursing documentation has all the necessary information. The phrase "If it wasn't documented, it wasn't done" is often heard to emphasize the importance of documentation to prove that the task was completed. However, it is considered partially true. Missing nursing documentation in the patient record can be challenging in defending the case in litigation. Similarly, "if it was documented but it was not done," fraud and false documentation can lead to a complaint to the nursing board. Errors in nursing documentation have contributed to a few negligence cases in patient care. These include incomplete nursing documentation, inaccurate information, missed documentation of significant patient clinical changes, and documentation that is not timely are common mistakes in nursing documentation (El Rahman et al., 2021). In the present digital era, nursing documentation using electronic software provides a means to document patient care and exchange information with the healthcare team. However, documentation in electronic form is cumbersome and has an associated burden. Nurses spend much time during their shifts performing nursing documentation, resulting in reduced time to provide direct patient care. The good news is that electronic health records have come a long way. The EHR workflow can be redesigned to reduce nurses' burden on nursing documentation and avoid redundancy in nursing entries. In Lindsay & Lyte's 2022 study, redesigned standardized nursing flowsheet documentation significantly reduced up to 12% of the total time spent by the nurses documenting in EHR flowsheets. At Houston Methodist, Epic EHR was adopted across the system, providing various functions. One of the functionalities in Epic flowsheet is called Macro Manager or Macros. Nurses can use the Epic Macros tool functionality to automate tedious nursing documentation in flowsheets. For example, complex and peripheral intravenous (PIV) assessments are the system Macros that nurses can use. How does Macros work for the complex assessment? Once all the exceptions on nursing assessments are documented, nurses can click on the within-defined limits (WDL) Macros to apply WDL to all other systems. Moreover, nurses can create personal Macros based on the most common nursing documentation. Houston Methodist nurse informaticists and the Epic tip sheets are helpful resources for nurses when creating and editing flowsheet Macros. Using the Epic Macros tool eliminates redundant nursing entries and unnecessary extra clicks in every aspect of the nursing documentation. Nurses face various constraints and challenges during their shifts that can result in omission or negligence in nursing documentation. However, it is an essential component of nursing practice and is vital to the nurses' clinical competency. Factual, Accurate, Complete, and Timely nursing documentation provides a clear picture of the overall patient's clinical conditions and the patient's response to interventions. All these components are nurses' best defense against litigation. Nurses can use the electronic health record's smart functionality to improve clinical nursing documentation. Optimizing EHR functions to minimize documentation time can increase patient care and enhance the quality of care. Nurses should adhere to the standards, rules and regulations, and organizational policies and procedures related to nursing documentation to protect themselves and their patients.