(4) Use of orders. Every action taken for the patient must be ordered by the
doctor. The doctor uses DA Form 4256 to order laboratory work, medication, diet,
therapy, and so forth. The nurse, technician, or clerk who is responsible must take note of
the orders, enter the time, and either sign or initial in the "List Time Order Noted and Sign"
column of this form.
b. Progress Notes by Nurses. The nurses responsible for the nursing care given
to a patient are required to document this care.
(1) Nurses' notes must chronologically describe the nursing care provided on
(2) SF 510 is designed so that the nurse will record the date and time of the
observation. Nurses' observations should include: a description of the patient's condition;
his vital signs; medication administered; treatment provided (when indicated), and any
other pertinent information reflecting the condition of the patient. Each note must be signed
by the nurse, giving rank and corps (if a military nurse) or rank and title (if a civilian nurse).
When the nurse notes an order by the doctor and carries out the order, the nurse must enter
the action on SF 510, including time, action taken, and signature. For example, if the
doctor's order states "Demerol 100 mg IM q 4 hr PRN," the nurse should enter on the
nursing notes "2100, Demerol 100 mg given IM for abdominal pain," and sign the entry,
including rank and corps. The importance of this cannot be overemphasized because if
the nurse fails to enter this data on the nursing notes, no one would know that the patient
had received the medication and another nurse may administer the medication again,
causing an overdose. A drug overdose could compound the patient's illness or result in