Purpose of Charting:
To make record of—
1. The significant observation of the patient’s condition both mental and physical.
2. The medication, treatment, diets and nursing care given and the reaction of the patient to this care.
3. The incident which might have some bearing on the patient’s condition.
General Rules for Charting:
1. All recording on the chart must be printed, except the written signature of the nurse.
2. The written signature of the nurse should consist of her initial of first name and fill last name.
(a) The signature should stand alone on the line just below the notations recorded by her.
(b) The signature of the nurse should be of a size that will insure legibility without attracting attention.
3. A nurse making a series of statements or notations signs for the series and not for each individual statement or notation.
4. The nurse should not go “off duty” without making the necessary notations on the charts of each patient assigned to her to cover the time of the assignment.
5. All recording on the chart should be neat, legible, intelligent and meaningful.
6. Statements must be accurate, relevant and concise.
(a) Terse statements instead of complete sentence are used.
(b) Correct spelling and only acceptable and official abbreviations are to be used.
7. Authentic recording is essential as a chart often plays an important part in the presentation of court evidence.
8. Print the proper headings for all new pages or sheets to be added to the chart using blue or black ink.
9. Keep all recordings within limits provided by the pale. Begin each separate notation on the horizontal lines where it intersects the vertical limiting lines.
10. Do not use ornamental lettering for recording on the chart.
11. Blue or black ink should be used for recording between the hours of 7:00am to 11:00pm.
12. Red ink should be used for recording between the hours of 11:00pm to 7:00am.
13. The midnight lines are to be drawn in red ink. Write the date and the day of the new day between the midnight lines.
14. In the hour column, record the time of treatment, medication, appearance of symptoms, doctor’s visit, etc.
15. In the “observations” column:
(a) Record any of all symptoms, complaints or change in the condition of the patient.
(b) Record all start and p.r.n. treatments and medications given.
(c) Record the results and effects of the medications and treatments.
(d) Record routine nursing procedures involved in the care of the patient.
(e) Record each time the attending physician visits the patient.
16. Never print the word patient when charting. The chart in itself is a record for the individual patient and all notations are in regard to the person for whom the record is kept.
