Charting & Military Time

1. Charting & Military Time Military Time Rules of Charting

2. Military Time • Military time is used in all health records • Do not use AM or PM • Write the time for every entry

3. Example • 1400 Pt watching TV. 2 tab Tylenol 200mg given for headache. Pt rates pain as 5 on a 0-10 pain scale. • 1405 Pt requests assistance to bathroom. Voided 200cc. Pt back in bed. Resting quietly. Pain remains 5 on a 0-10 pain scale.

4. Practice • 2:14 PM • 3:00 AM • 12:00 PM • 1:15 PM • 10:25 AM • 5:30 AM • 2:20 AM • 11:30 AM • 9:25 PM • 12:00 AM

5. Charting • Charting is a written picture of care given to the patient • All charting is confidential (only those directly related to care) • All charting is a legal document

6. Rules of Charting • After documenting, sign the chart with first initial, last name, & title (L. Jordan, RN) – your title (HSS) • “ Ditto” marks, white out, erasures, blacking out is NEVER acceptable ways to make corrections • Never chart before a task is performed • Record observations, procedures, pt’s reactions, complaints, & behavior • No blank lines. Do not skip lines.

7. Rules of Charting 6) Use military time • Only blue or black pen • Use medical abbreviations. Write neatly. Spell correctly • Correcting mistakes = draw one line through the mistake, write ERROR above with initial • No blanks to the right of your signature

8. Example • At 9:00am, you enter the patient’s room and give 1 tablet of Motrin 600mg. • One hour later, you return to check vital signs which are: temperature 98.8, pulse 88, respirations 20, and blood pressure 120/80. • At 11:30am, you check the patient’s incision dressing and see that it has a dime size amount of clear drainage on the dressing. You replace old dressing with a clean, dry dressing.