Specific Guidelines

Physician's orders

1. Each order should have the date and time it was written. 
2. Some way of indicating which orders have been carried out is necessary. 
3. 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

1. Graphic' records for temperature, pulse and blood pressure must reflect accurately the client's actual vital signs. 
2. 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. 
3. All treatments and procedures must have the time at which they occurred. 
4. There should be place to chart the patient's/client's response, untoward side effect and result.