General Guidelines

While working in the ward, you are always required to record. You should follow the general guidelines while recording which are as follows:

1. All entries on the chart must be accurate and factual. 
2. Exactness is essential in changing times, effects and result of treatments and procedures. 
3. Full dates including year should be written. 
4. Use ink while entering and write legibly. 
5. Each entry must follow by your first initial, last name and title. 
6. Ditto mark and erasers are not acceptable. Errors are corrected by drawing a single line though the incorrect material and writing in the correct entry as close to the mistaken entry as possible.
7. Lines should not be left completely or partially blank in the record. If a line is skipped or not filled completely, draw a single line through the remainder to prevent charting by someone else. 
8. Descriptions are essential when charting about drainage, stool, vomitus, pain and any other diagnostically valuable occurrence. 
9. The time should be recorded on all entries. 
10. Only abbreviations accepted by the hospital are allowed on the record. 
11. Each page of the chart must be identified with the name of the patient/client, hospital identification number and any other data required by the hospital. 
12. The reliance on various facilities as a means to reimbursement for health care facilities had placed increased emphasis on the need for accurate documentation. 
13. The chart should reflect nursing assessment and nursing therapy prescribed by the professional registered nurse and reflected on the nursing care plan.