Charting for Nurses Follow these rules for charting

Charting for Nurses  Follow these rules for charting

chart everything:
include observations,
nursing actions,
patient’s response to therapy and treatment,
any unusual incidents or omitted treatments
safety precautions you took to protect the patient
your attempts to reach the doctor
any reservations you have about a doctor’s orders
the date and time of each entry
the patient’s name and identification number off the chart
your signature on each entry (when in doubt chart everything)
leaving blanks or omitting documentation could have disastrous