Charting

The classic saying is 'if it isn't charted it isn't done' which is always a good rule to stand by.  There are a couple more tips that can be helpful:
Do not depend on EMR to help you remember. Make narrative notes.  Paint a picture of the patient that you are seeing before you. If you are ever questioned about the care you gave, whether from the board of nursing or in a legal proceeding your charting should be substantial enough to trigger your memory of event or at least you know what exactly you did for this patient and what you saw.
Assess-intervene-reassess- did your intervention work or not and what did you do about it? If there was an abnormal finding was it addressed or explained and what was the resolution. 
Take credit for your work!! We all work very hard, you shouldn't be the only one who knows all the work you do.