1-16. NURSING NOTES (SF 510)
The Clinical Record--Nursing Notes form (figure 1-15) is used to record objective
observations of the patient's condition, including his physical and mental status,
symptoms, response to diagnostic or therapeutic procedures, and changes noted in any
of these aspects. The Nursing Notes reflect the response or status of the patient to all
nursing care measures documented on the Nursing Assessment and Care Plan forms
(DA Forms 3888 and 3888-1). All entries are significant and contain data relevant to
nursing care. The administration and the effectiveness of all p.r.n. (as needed) and stat.
(immediate) medications are recorded on the SF 510. The form is also used to
document diagnostic procedures, therapeutic procedures, special nursing procedures,
and unusual occurrences. In addition to aiding in diagnosis and treatment, information
on the form can be used for research, teaching, and/or evidence in the event of
litigation. When the front of the form is filled, the reverse side is used. Both sides of the
form are the same except for the "Patient Identification" section which is located only on
the front side. The Nursing Notes forms become a permanent part of the patient's MTF.
1-17. MAKING ENTRIES ON THE NURSING NOTES
a. Patient Identification. If a new form is being initiated, print the identification
information in the Patient Identification block in ink or imprinted the information using an
addressograph, the inpatient plate, and the ward plate. If the information is imprinted,
all new pages must be imprinted exactly as the original. In figure 1-16, the local SOP
includes the admission date on the inpatient plate.
b. Date/Hour. For each separate entry made, enter the day, month, and year in
the Date column and the time of the entry (in military time) in the appropriate Hour
column (AM or PM). If another entry is made on the same date, you must enter the
date and time again. Ditto marks are not acceptable.
c. Observations. Write (chart) all entries on the Nursing Notes with black or
blue-black ink. The entry can be either printed or in cursive writing, but it must be
legible. Do not skip lines or write between lines. Begin each entry with a capital letter.
Make the entry objective (who, what, where, when), clear, and concise. Use the term
"appears" when recording your observations, and record specific data such as time,
severity, location, duration, amount, size, frequency, and type. Use only standard,
approved abbreviations (AR 40-66). Use only present tense or past tense verbs. Make
your entry as soon as possible after the event since you may forget to record pertinent
information if you delay too long.