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NURSE'S NOTES: Obsolete Terms in Nurse's Chart

This document provides guidance on replacing obsolete terms in nurse charting with more descriptive and specific phrases. It lists 10 obsolete terms, the reasons they are obsolete, and suggested replacement phrases that provide more useful clinical information. The replacements focus on documenting objective assessments, interventions, and evaluations rather than vague statements. For example, rather than "afebrile" documenting the temperature and any fever treatment provided.

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48 views1 page

NURSE'S NOTES: Obsolete Terms in Nurse's Chart

This document provides guidance on replacing obsolete terms in nurse charting with more descriptive and specific phrases. It lists 10 obsolete terms, the reasons they are obsolete, and suggested replacement phrases that provide more useful clinical information. The replacements focus on documenting objective assessments, interventions, and evaluations rather than vague statements. For example, rather than "afebrile" documenting the temperature and any fever treatment provided.

Uploaded by

bhongskirn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSE'S NOTES: Obsolete terms in Nurse's Chart

(Obsolete term ---> Reasons ---> Suggested Phrase)


1. Conscious and Coherent---> only for patient whose neurological status is affected
and disoriented ---> Patient oriented to date, time and place.
2. Vital Sign taken ---> vital sign are already written in monitoring sheet ---> Document
only if you were not able to take vital sign and why.
3. Afebrile---> temperature is written in monitor sheet ---> if the patient is febrile, support
it with subjective and objective cues. Evaluate effectiveness of nursing intervention for
fever; include the element of time.
4. Due medications given ---> recording is given in medication sheet ---> Document
medicines that were not given and its reason. Document STAT medicine given, its
indication and evaluate the effectiveness.
5. Seen at interval ---> it is expected that we visit patient in interval ---> visit patient
frequently and assess for any complication.
6. Needs attended / Kept comfortable / Kept undisturbed / Kept safe ---> it is expected
that we make the patient comfortable during their stay in the hospital ---> Enumerate
measures done to make the patient comfortable. Verbalized needs must also be
documented and referred to Doctors as necessary.
7. Slept fairly / sleep well / asleep the whole shift---> only noted if the patient is having
difficulty in sleeping ---> if the patient has difficulty in sleeping document the subjective
cues, intervention done and evaluation. Slept for approximately 5 hours as verbalized
by patient.
8. MGH ---> it should be "Patient seen by Dr.____ with discharge order given".
9. On DFA / With fair appetite ---> it should be "Patient was able to eat half of the food
served for lunch". You may include the intervention given regarding prescribed diet and
patient compliance. " Encourage to eat prescribed diet and the importance. Verbalized
understanding".
10. No complains made / No pain--> if with pain, note the pain and characteristic
(PQRST).

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