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- 1. DOCUMENTATION RAHIMA M. SALENDAB BSN, RN.
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- 7. DOCUMENTATION MUST BE: 1. 2. 3. 4. 5. 6. 7. Neat and Legible Proper spelling and grammar Clear and concise sentence Follow color code (BLACK & BLUE INK) when writing notes Use authorized / standard abbreviations ONLY Transcribe order carefully Chart promptly (as soon as observation, nursing care, treatment and or procedure done) - -
- 8. 8. Time with initial in each entry 9. No blank space every after entry 10. Correct mistakes entries properly by: a. Draw a line across the mistaken entry and write M.E. on top b. Never scratch out when correcting error c. Never use liquid corrector 11. Late entry must be identify clearly 12. Write full name when closing the notes 13. All entry must be written in ENGLISH - 10 M.E) -
- 10. DATE TIME 01/01/1434 O7:30H 08:00H 08:45H 09:00H 12:30H 13:00H PROGRESS - - 10:30H - Received pt on bed awake, conscious and oriented, afebrile, with IV cannula size 22G in left arm, with ongoing IV Normal Saline 500 cc at the level of 200 cc, infusing well ------------------------------------------V/S checked and recorded ------------------------------Seen and examined by Dr. Musa with orders made and carried out --------------------------------------------Blood for CBC extracted, sent to lab Lunch served, ate with fair appetite -------------------To keep NPO post-midnight for possible OR tomorrow --------------------------------------------------M.E. Fax send to KFH for CT brain -------------------------“Late entry” abdominal ultra sound done, report seen by Dr. Musa --------------------------------Closely watched and attended --------------------Endorsed --------------------------------------------------- SIGNATURE A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi A. Al-Harbi Amal AlHarbi
- 11. NEVER USE LIQUID CORRECTOR
- 12. SAMPLE DOCTORS ORDER DATE TIME 01/01/1434H 08:45H PROGRESS NOTES - SIGNATURE For blood transfusion, 2 units PRBC after cross matching DR. MUSA ALI MEDICAL SPECIALIST (STAMP) Noted by: A. Al-Harbi 01/01/1434 at 08:45H Reviewed by: M. Al-Oufi 01/01/1434 at 01:00H (RED INK) Must be done by AM shift and or on admission by any shift Must be done by night shift
- 13. 24 HOURS / MILITARY TIME 2400 1300 2300 1200 0100 1100 2200 1400 0200 1000 2100 0300 0900 1500 0400 2000 1600 0800 0500 0700 1900 0600 1800 1700
- 14. If you are not willing to learn, No one can Help you. NO ONE CAN MOTIVATE…. IF YOU ARE NOT WILLING TO DO YOUR SELF… THANK YOU If you are determined to learn, No one can stop you …!!!