HEAS 1000

STUDENT NAME (please print): ____________________________ID#__ _____

Client Care Record

Date Time Nurse’s Notes

Documentation Guidelines:

Format:

 Permanent black/ blue ink

 Correct Date format: Day

Month Year (e.g. 07 Feb
2016)

 Time – use 24-hour clock

(no colons or semi colons)

 Signature (1st initial, last

name and designation
(eg. J Smith SPN )
 Correct error appropriately
(single line, initial, mistaken
entry )
 No blank spaces at the end
of line or between entries
 No abbreviations
 For sequential page
documentation, signature
at bottom of 1st page. On
second page, time, date
and “continued”.

Content:

 Indicated how patient was

found.

 Indicated safety
precautions (side rails &
call bell in reach?) How was
client left?

 Did not use the word

“patient” or “client” in
charting.

 Chronological/sequential
manner

 Subjective information-
what the client says about
herself or himself

 Accurate documentation
for inspection
 Accurate information for
palpation.
 Accurate information for
auscultation, or other key
May 17, 2018
HEAS 1000

systems.
 Correct spelling
 No double charting (do not
chart vitals unless
abnormal, chart “Vital signs
taken, see flow sheet”.
 Document what you have
done, not what you will do.

Date Time Nurse’s Notes

May 17, 2018

HEAS 1000

Jarvis, C. (2014). Physical examination & health assessment (2nd Canadian ed. p 66). Toronto, ON: Saunders Elsevier.
Retrieved from: http://studywithclpna.com/nursingdocumentation101/

May 17, 2018