d. Recording Special Procedures. Always document diagnostic, therapeutic,
and nursing procedures and the patient's condition before, during, and after the
procedure. Record the name of the procedure, the time that the procedure was
performed, the name of the person performing the procedure, any information or
instructions given to the patient, a description of what was done, and any laboratory
data, x-ray reports, or other records pertinent to the procedure.
e. Recording Other Information. Record all medications and treatments given
to the patient. Record the patient's vital signs (TPR/blood pressure (BP) and, if
applicable, daily intake and output. Record any unusual occurrences, especially any
falls or similar happenings. When possible, use laboratory data to verify observations
recorded on the Nursing Notes.
f. Correcting Entries. If an error is made on the form, do not erase the
mistake or blot out the mistake to make it illegible. Instead, draw a single line through
the error (the error must remain readable), enter your initials above the lined-out entry,
and enter the correct information following the lined-out entry.
(NOTE: The same procedure is used for correcting any entry on any permanent
medical record form.)
g. Signing Entries. Each entry in the Observations section of the Nursing
Notes form must be signed by the person making the entry. If you make an entry in the
Nursing Notes, write your payroll signature, rank, and status (MOS, corps, and so forth)
after the entry without skipping a line. Draw a single line through any blank space
preceding or following your signature block to prevent another person from including
any other information in your entry.
1-18. MAKING SPECIAL ENTRIES ON THE NURSING NOTES
a. Subjective Objective Assessment Planning Format. Some facilities use
the subjective, objective, assessment, and planning (SOAP) format when charting
pertinent information. Information is arranged according to type (subjective, objective,
assessment, and planning). Each section of the entry is preceded by the appropriate
letter (S, O, A, or P) to make referencing easier. Medical specialists will usually only
make subjective and objective type entries. Assessment and planning type entries are
usually made by a physician, nurse, or physician assistant.
(1) Subjective ("S") information is information obtained from the patient,
relative, or similar source. When making an "S" entry, use the patient's own words
when possible. For example, "Patient states, 'I am having pain in my right calf.'"
(2) Objective ("O") information is based upon your observations of the
patient or upon diagnostic or laboratory tests (you observe the test data). Basically,
objective entries are what you see, feel, and hear. Vital signs are recorded in this