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
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
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 …!!!