1-13. NURSING ASSESSMENT AND CARE PLAN (DA FORMS 3888 AND 3888-1)
The Medical Record--Nursing Assessment and Care Plan (DA Form 3888)
shown in figures 1-8 and 1-9 and the Medical Record--Nursing Assessment and Care
Plan (Continuation) (DA Form 3888-1) shown in figures 1-10 and 1-11 document a
baseline nursing history and assessment for the patient. They are also used to record
identified problems and desired results of planned nursing intervention. DA Form 3888
consists of the nursing history and assessment information needed by the nurse to plan
individual patient care. Additional information is recorded on DA Form 3888-1 as
determined by the professional nurse. The reverse side of DA Form 3888-1 is used in
conjunction with the DA Form 4677, Therapeutic Documentation Care Plan (Non-
Medications). Although the professional nurse is responsible for the preparation of DA
Forms 3888 and 3888-1, all persons involved in the patient's care contribute to the
development of the care plan.
a. The forms are kept readily available to all members of the nursing care team
for their review and input. The forms are kept in a metal folder separate from the one in
which the patient's SF 510, SF 511, DA Form 4256, and DA Form 4677 are kept.
b. When the patient is dispositioned (other than transfer), the forms become a
permanent part of the patient's MTF. In the event of transfer, they are sent with the
patient to the next ward or MTF.
1-14. DOCTOR'S ORDER (DA FORM 4256)
The Clinical Record--Doctor's Order form (figure 1-12) is a three-part carbonless
form maintained in the patient's chart. All orders made by the physician are recorded on
the Doctor's Order form. The original (white) copy remains with the chart while the
second (pink) copy is sent to the pharmacy. The pharmacy receives a copy of all orders
to ensure proper supervision of food-drug and laboratory- drug interactions. The third
(yellow) copy is used to communicate all orders to the nursing staff. Additional uses
may be made of the yellow copy as determined by local policy. The yellow copy is
destroyed when no longer required. The original copy eventually becomes part of the
patient's MTF.
1-15. THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATIONS)
(DA FORM 4677)
The Clinical Record--Therapeutic Documentation Care Plan (Non-Medications)
form (figures 1-13 and 1-14) is printed on colored paper. The form is used to document
accomplishment of tests, treatments, and nursing orders. Actions carried out on a
recurring basis or on a one-time or p.r.n. (as needed) basis are also recorded. Medical
orders from the Doctor's Orders form are transcribed onto this form. Nursing orders
initiated by the professional nurse are written on this form and must be signed at the
end of the order by the nurse initiating the order. This form is maintained in the patient's
chart and becomes a permanent part of the patient's MTF.
MD0920
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