Completeness and chronology/organization/sequence/timing.
Notes should appear on each succeeding line
Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new idea or entry.
Date is entered in the date column on the first line of every page of nurse’s notes and whenever the date changes.
Time is entered in the time column whenever a new time entry occurs.
Avoid time changes in the text of nurse’s notes.
Avoid double chart. If something appears on a particular sheet, it does not need to appear on the nurse’s notes, unless there is an alternation from the normal, e.g. body temperature, blood pressure.
Avoid squeezing information to a space because you forgot to chart it earlier. Add the information on the first available line. Write the time the event occurred, not the time you entered the information.
Antonio, a 55 y/o farmer, was found by his son lying on the floor unconscious. He was brought to the ER and was diagnosed with CVA, probably bleed. He is then admitted to the medical ICU for continuity of critical care. He is drowsy, restless at times, severely dyspneic, and with excessive secretions. Crackles are heard upon auscultation at both lower lung fields. V/S: BP 190/110mmHg, T° 39°C, RR 38cpm, PR 112bpm