NURSING SERVICE OFFICE Policy and Procedure
CHARTING/ Doc. No.
Rev. No. 00
DOCUMENTATION Page No.
Effective Date:
Page 1 of 3
1. PURPOSE:
The primary purpose of the chart is to ensure continuity, coordination, and safety of
client care. The chart provides data for planning of client care, communicates the
application of the nursing process in the delivery of client care and serves as a legal
record of the plan of care and progress of the client in chronological order from the
time of admission up to the time of discharge.
2. SCOPE:
This policy and procedure communicates the application of the nursing process in
the delivery of quality nursing care from the time of admission up to the time of
discharge
3. POLICY:
Effectivity of this procedure can be attained upon the implementation of the following
policies:
3.1. Documentation by the staff nurses shall reflect the Nursing Process:
Assessment, Outcome Identification, Planning, Implementation, and Evaluation
3.2. Documentation in the patient’s record shall be done by the staff nurses except
as outlined below:
3.2.1. Students may document nursing care as part of their training provided that
a sample charting has made and countersigned by their respective clinical
instructors
3.3. Changes in an individual’s physical or mental condition and abnormal laboratory
results shall be reported immediately to a Registered Nurse who will assess and
report promptly to the attending physician as appropriate. The date, time, and
method of notification including pertinent information on the patient shall be
relayed to the physician and shall be entered in the patient’s chart
3.4. Errors in documentation in the patient’s chart shall not be obliterated by use of
“white-outs” / correction tape or any other means
3.5. All documentation in the patient’s chart shall be done in black for AM duty, blue
for PM duty and red ink for NIGHT duty except as stated below:
3.5.1. Red ink shall be used on the medication sheet and standing order sheet to
discontinue medication/treatment
3.5.2. Red ink shall be used to document “Allergies/Alert” on the Physician’s
Order Sheet, Medication Sheet
3.5.3. Red ink shall be used to note physician’s order and to draw the red line on
the Physician’s Order Sheet (POS) or Doctors’ Order Sheet (DOS) to note
the 24-hour Audit Check
3.6. Chart neat, legible entries. Print if the handwriting is not legible.
3.7. FDAR charting shall be utilized by all nurses in documenting the nursing care
provided for the patient
NURSING SERVICE OFFICE Policy and Procedure
CHARTING/ Doc. No.
Rev. No. 00
DOCUMENTATION Page No.
Effective Date:
Page 2 of 3
3.8. Self – inking stamp or TRODAT shall be used by the staff nurses in carrying out
doctor’s order. If unavailable, staff nurse shall print individual’s name and license
number with the date and time the order was carried out or the nursing
procedure was done
3.9. All entries must be dated and include the time the entry was written. All ‘late
entries’ must also include date and time written
3.10. Staff nurses shall not make judgments or assumptions without justification
or evidence. Chart using descriptive, quantitative and objective information
about the client. Use the patient’s own words if possible, in describing signs and
symptoms. Use the word ‘state’ or ‘stated’ when charting client statements
3.11. Avoid leaving blank spaces in the chart. If you end a notation part way
through a lined space, draw a line in ink to the right hand margin
3.12. All information in individual’s chart is CONFIDENTIAL. No information
should be discussed with unauthorized personnel. (Authorized personnel are
those who need to know information to give care to the client)
4. PERSONNEL RESPONSIBLE:
4.1. Staff Nurses – shall be responsible in documenting/ charting of the nursing care
provided to the patient
4.1.1. Ensures accurate documentation utilizing the nursing process from the
time the patient is admitted up to the time the patient is admitted to the
hospital
4.1.2. Performs assessment and re-assessment of patient treatment and care
plan
4.1.3. Observes guidelines on proper documentation
4.2. Head Nurses
4.2.1. Ensures utilization of the nursing process by the staff nurses from the time
the patient is admitted up to the time of discharge
4.3. Supervisor
4.3.1. Enforces guidelines in carrying out doctors and proper documentation of
the nursing care provided to the patient
5. PROCEDURE:
5.1. In case of error or entry mistake
5.1.1. Do not erase or use ‘white out’, instead draw a single line through the
center of the notation
5.1.2. Write ‘error’ above the notation and then initial
5.2. In recopying of page
5.2.1. Draw a diagonal line through the page and then write the words “Original
Copy” at the top
5.2.2. Retain the original copy with the recopied page
NURSING SERVICE OFFICE Policy and Procedure
CHARTING/ Doc. No.
Rev. No. 00
DOCUMENTATION Page No.
Effective Date:
Page 3 of 3
5.2.3. At the top of the new page write “Recopied” and then sign name and
status at the top of both pages
5.3. In case of late entry
5.3.1. Write current date and time and state the reason for late entry
5.3.2. Document particulars of the late entry, sign name and status on the right
hand column on the last line used for notation
5.4. Continuation of page
5.4.1. Sign name and status at the bottom of the first page with the word “Con’t”
and continue the documentation on the top of the new page
5.4.2. On the new page, write the date and time at the top and sign name and
status on the last line used for notation
5.5. For unusual occurrences – critical /non-critical incidents
5.5.1. Write the date and time of initial entry in nurses’ progress note sheets
5.5.2. State facts about the time and circumstances of the vent and the actions
taken to safeguard the patient
5.5.3. Sign name and status in the right hand column on the last line used for
notation
5.5.4. The documentation in the nurses’ progress note is in addition to the
incident report form
5.6. For cases of temporary absence or “out on pass”
5.6.1. Record in the nurses’ progress notes including the time of departure and
return, destination and mode of transportation
