General Rules for Charting

• Spelling
- Make certain you spell correctly

• Accuracy
- Records must be correct in all ways, be honest

• Completeness
- No omission, avoid unnecessary words or statement

• Exactness
- Do not use a word you are not sure of

• Objective information
- Record what you see avoid saying (condition better)

• Legibility
- Print/write plainly and distinctively as possible

• Neatness
- No wrinkles, proper speaking of items
- Place all abbreviation, and at end of statement

• Composition / arrangement
- Chart carefully consult if in doubt avoid using of
- chemical formulas

• Sentences need to be complete and clear, avoid repetition
• Don’t overwrite
• Don’t leave empty spaces in between
• Time of charting
- Specific time and date

• Color of ink
- Black or blue (red for transfusion, days of surgery)

It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit.