Specific Guidelines
Physician's orders
- Each order should have the date and time it was written.
- Some way of indicating which orders have been carried out is necessary.
- The professional nurse who assumes responsibility for noting the order must sign time, name and title to verify notation of the orders.
Graphic records, treatments and procedure sheets
- Graphic' records for temperature, pulse and blood pressure must reflect accurately the client's actual vital signs.
- Descrepancies such as elevated temperature or abnormally depressed pulse should be reported to the senior nurse or physician responsible for the patient's/client's care.
- All treatments and procedures must have the time at which they occurred.
- There should be place to chart the patient's/client's response, untoward side effect and result.