Purpose of Charting: To make record of—
- The significant observation of the patient’s condition both mental and physical.
- The medication, treatment, diets and nursing care given and the reaction of the patient to this care.
- The incident which might have some bearing on the patient’s condition.
General Rules for Charting:
- All recording on the chart must be printed, except the written signature of the nurse.
- 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.
- A nurse making a series of statements or notations signs for the series and not for each individual statement or notation.
- 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.
- All recording on the chart should be neat, legible, intelligent and meaningful.
- Statements must be accurate, relevant and concise.
(a) Terse statements instead of complete sentence are used.
- Authentic recording is essential as a chart often plays an important part in the presentation of court evidence.
- Print the proper headings for all new pages or sheets to be added to the chart using blue or black ink.
- Keep all recordings within limits provided by the pale. Begin each separate notation on the horizontal lines where it intersects the vertical limiting lines.
- Do not use ornamental lettering for recording on the chart.
- Blue or black ink should be used for recording between the hours of 7:00am to 11:00pm.
- Red ink should be used for recording between the hours of 11:00pm to 7:00am.
- The midnight lines are to be drawn in red ink. Write the date and the day of the new day between the midnight lines.
- In the hour column, record the time of treatment, medication, appearance of symptoms, doctor’s visit, etc.
- 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.
- 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.
- Do not write the orders of the doctor as “Dr. Smith ordered backrest elevated two inches.”
- Arrange the different sheets on the chart in correct order.
- Errors in charting:
(a) Do not erase errors made in charting
(b) When an error has been made, draw a line through the error from the upper left hand corner to the lower right hand corner to inchide the necessary space containing the error and write the word “ERROR” under which the nurse signs her name.
(b) The signature of the nurse should be of a size that will insure legibility without attracting attention.
(b) Correct spelling and only acceptable and official abbreviations are to be used.
(e) Record each time the attending physician visits the patient.
(c) An error in charting should not necessarily invoke recopying of the entire page. Consult the supervisor or headnurse before copying a page on which you have made an error. It is necessary to recopy, the original page must be filed at the back of the chart.
Charting the Nurses’ Records
General Rules for Printing:
- Printing is the most consistently legible of all forms of writing for that reason should be used for recording on hospital charts.
- Print well formed, individual letters in each ward.
- Properly space all printed letters and words.
- Do not use more than one space for each letter, regardless of the shape of that letter.
- Separate printed words by a space the size of single letter.
- Do not use unnecessary curves tails or fancy strokes in making the printed letters.
- Make all printed letters stand erect.
- To avoid illegibility, do not make too much of a forward backward slant to the letters.
- Make all printed letters conform in appearance to those in the sample alphabet.
- Make each printed letter rest on the line.
- Always make the small letter 2/3 the height of capital ones.
- Make the letter “U” curved at the bottom, make the letter “V” with art acute angle at the bottom.
- Cross the letter “t”, horizontally at the upper third of its height.
- Make the use of the word “bed” to remember on which side of the stem to make the loop for the letters “b” and “d”.
- For practice in printing use only those letters which are illustrated in the sample alphabet.
- Print numbers that are to be used in charting as well as letters.
Example of Data to be Charted:
- All doctor’s orders.
- (a) Medicines given, the time at which they are, and when, used to relieve a condition that should respond to treatment within a short time.
- (a) Treatment given, time and effect on patient’s condition during or after the treatment, or results of flow in cases or irrigations, etc.
- When recording the dressing of wound, state condition of the letter, if there is discharge, mention and change in the treatment or dressing by whom and time.
(1)All conditions that call for particularly careful attention to their record e.g. following surgical operation or X-ray or other treatment that may-have harmful effects, accidents, chills, convulsions and when patient is very ill.
(3)Nature of excreta or order discharges, etc.
- Amount of sleep.
- Appetite and amount of food taken.
(b) Inspections, or punctures done, time result, and by whom.
(b) Operation delivery, kinds, time, TPR after.