a. Patient Identification. The "Patient Identification" section at the bottom
gives the patient's name, social security number, hospital (register) number, ward to
which the patient is assigned, and other information.
b. Heading.
(1) Month-Year/Day. The third line gives the calendar day. The calendar
month and year are on the fourth line under "Month-Year."
(2) Hospital Day. The first line tells how many days the patient has been in
the hospital. The day that the patient enters the hospital is "hospital day 1."
(3) Post-Day. This line tells how many days it has been since the patient's
surgery or since the patient delivered (gave the birth). This line is left blank if it does not
apply. For example, "DOS" (day of surgery) is entered on the date that the surgery
occurred. The number "1" entered in the next day's column. A "DOD" entry means
"day of delivery" (day that the patient gave birth).
(4) Hour. The fourth line is used to record the hours at which the patient's
vital signs are taken (not when they are actually recorded on the form).
(a) The graphic section of the form is broken into seven major sets of
columns. Each set is used to record the vital signs for a single day.
(b) Each of the seven major columns is divided into two of columns.
The first set is used for recording the vital signs taken in the a.m.; the second set is for
recording the vital signs taken in the p.m.
(c) Each of the two columns is divided into three columns by dotted
lines. Each dotted line column contains a single set of vital signs. This allows six sets
of vital signs (one set every four hours) to be recorded each day.
(d) The time that the vital signs are taken is recorded at the top of the
column on the fourth line. Civilian time is used. This means that vital signs taken at
0200, 0600, 1000, 1400, 1800, and 2200 (a typical schedule) would have column
headings of "2," "6," "10," "2," "6," and "10" respectively.
c. Vital Signs.
(1) Pulse. The pulse is graphed as an open or empty circle (o). It is read
using the "Pulse" column on the left of the form. Each solid horizontal line denotes 10
beats per minute. There are four dots between each pair of horizontal lines. Each dot
adds two beats per minute to the line below. For example, the patient's pulse rate at
1000 on 15 December 1985 as shown in figure 6-2 is 76. On the SF 511, the pulse rate
symbols are connected by straight lines.
MD531
6-10