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Charting & Military Time

Charting & Military Time. Military Time Rules of Charting. Military Time. Military time is used in all health records Do not use AM or PM Write the time for every entry. Example. 1400 Pt watching TV. 2 tab Tylenol 200mg given for headache. Pt rates pain as

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Charting & Military Time

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  1. Charting & Military Time Military Time Rules of Charting

  2. Military Time • Military time is used in all health records • Do not use AM or PM • Write the time for every entry

  3. Example • 1400 Pt watching TV. 2 tab Tylenol 200mg given for headache. Pt rates pain as 5 on a 0-10 pain scale. • 1405 Pt requests assistance to bathroom. Voided 200cc. Pt back in bed. Resting quietly. Pain remains 5 on a 0-10 pain scale.

  4. Practice • 2:14 PM • 3:00 AM • 12:00 PM • 1:15 PM • 10:25 AM • 5:30 AM • 2:20 AM • 11:30 AM • 9:25 PM • 12:00 AM

  5. Charting • Charting is a written picture of care given to the patient • All charting is confidential (only those directly related to care) • All charting is a legal document

  6. Rules of Charting • After documenting, sign the chart with first initial, last name, & title (L. Jordan, RN) – your title (HSS) • “ Ditto” marks, white out, erasures, blacking out is NEVER acceptable ways to make corrections • Never chart before a task is performed • Record observations, procedures, pt’s reactions, complaints, & behavior • No blank lines. Do not skip lines.

  7. Rules of Charting 6) Use military time • Only blue or black pen • Use medical abbreviations. Write neatly. Spell correctly • Correcting mistakes = draw one line through the mistake, write ERROR above with initial • No blanks to the right of your signature

  8. Example • At 9:00am, you enter the patient’s room and give 1 tablet of Motrin 600mg. • One hour later, you return to check vital signs which are: temperature 98.8, pulse 88, respirations 20, and blood pressure 120/80. • At 11:30am, you check the patient’s incision dressing and see that it has a dime size amount of clear drainage on the dressing. You replace old dressing with a clean, dry dressing.

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