Nurses Charting Purposes General Rules
Every Hospital or
Organisation Maintain and Keep some types Charts,
Charting is
essential for Staff Nurses
Charting is brief
account of client data regarding finding of Staff Nurses Examination and Nursing
Interventions
Nurses Charting Purposes General Rules
- Important to patient for future reference.
- Necessary for hospital to show quality of work done for patient.
- Needed by nurses and physicians as scientific record of diagnosis, treatment and progress.
- Important in legal defence as witness.
- Needed in research for accurate scientific data.
- Aids in formal and informal education.
GENERAL RULES FOR STAFF NURSES CHARTING:
- All recording on the chart must be printed except the signature.
- The signature should consist of the initial of the family names and name.
- A nurse making a series of statements should sign only once for the series.
- Record after a medication or treatment is given, not before.
- Blue ink should be used for recording between the hours of 7 a.m. to 7 p.m.
- Red ink should be used for recording between the hours of 7 p.m. and 7 a.m.
- Do not erase a mistake in printing copy the recorded notation, correcting the error.
- If an error is made in recording draw a red line through the error, write the word “error” your signature above the line.
- Printing the proper headings for all new pages to be added to the chart.
- Record the attending doctors visit whenever the nurse sends a call or special visit done by the doctor.
- Record any unusual symptoms or any change in condition of the patient.
- Arrange pages of the chart in correct order according to the policies of the institution when the patient i.e., admitted and discharged.
- Place all recorded notations in the column to which they belong according to the various column headings.
- Do not word a recording in future tense, as backrest to be elevated.
- Never printing the ‘patient’ on the chart if self is a record for each individual patient and all notations made are in regard to the person for whom the record is kept.
- The title will be recorded for each new entry.
- Recording will be done by the nurse who cares for the patient, administers the medication or treatment.
- At midnight a line is drawn horizontally across the page below the last recording and the date written in the proper column.
- Only standard abbreviation should be used.
CHARTING SHOULD BE:
- Pertinent
- Honest
- Neat
- Legible
- Clear and accurate
- Concise and complete
- Recorded in proper places
- Each entry should convey a complete thought.
RECORDING SHOULD INCLUDE:
- Observation and reports of subjective symptoms which indicate a change in the condition of the patient his behaviours or mental attitude.
- Medications, treatment and nursing care given and observable effects.
- Specimens sent to the laboratory.
- Accidents to unusual happenings.
- Diet taken, amount of food taken if significant.
