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Nursing Profession

Nurses are required to document patient care and interventions in patient charts. At Saint Louis Hospital of the Sacred Heart, different colored ballpoint pens are used in documentation to identify the shift - black for 7-3, blue for 3-11, and red for 11-7. This helps trace interventions back to the responsible shift and nurse if issues arise. The author received an incident report for using the wrong colored pen while documenting, highlighting the importance of following this procedure to ensure accurate record keeping.

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Liezel Ann Esteban
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2K views1 page

Nursing Profession

Nurses are required to document patient care and interventions in patient charts. At Saint Louis Hospital of the Sacred Heart, different colored ballpoint pens are used in documentation to identify the shift - black for 7-3, blue for 3-11, and red for 11-7. This helps trace interventions back to the responsible shift and nurse if issues arise. The author received an incident report for using the wrong colored pen while documenting, highlighting the importance of following this procedure to ensure accurate record keeping.

Uploaded by

Liezel Ann Esteban
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Liezel Ann Esteban BSN II-C Charting: Use of Different Inks

Theology 4 March 12, 2012

Nursing profession is the largest force of health care system with the role of providing care. Caring for our patients does not limit in staying in the bedside and helping them to recover. We need also to document the nursing interventions we made. In the process of documentation, we need the patient's chart which is situated in the nurses' station. In the patient's chart, there is a part called the nurses' notes. In this nurses' notes, nurses document the certain problem they have seen with their patients within their shift; the subjective and objective data regarding their patients; the nursing diagnosis they formulated and the diagnostic, therapeutic and educative interventions done by the nurse to their patients are also written in here. This documentation is called SOAP charting. The process involved in writing SOAP is not that simple. There is a need to use different kind of ballpens in every shift. In the premises of Saint Louis Hospital of the Sacred Heart, the 7-3 shift uses black ballpen, 3-11 shift uses blue ballpen while the 11-7 shift make use of red ballpen. This supports the claim of American Nurses Association guidelines that nursing is an art. Why do we need to use different inks of pen in charting? Why can't we use our ink of choice in documentation? What is the importance of using different inks of pen in charting depending on your shift? These are the questions that comes to my mind, now that I'm having my duty as a student nurse. According to Sir Dan Abalus, my clinical instructor in the pedia ward, we need to use different inks of pen for identification purposes. It is important to know what shift and who made a certain intervention that helps the client to recover or worsens the health status of the patient. Even though, the signature of the nurse or student nurses are written after the chart and the date and time is indicated, it is more organized if different inks of pen were used. For example, during the 2:00 pm, Student A had given a wrong intervention in the patient like putting a hot water bag for a patient who have appendicitis. This causes the rupture of appendix of the patient during the 3-11 shift. Upon looking at the chart, it is easy to traced what shift and who made the wrong intervention if different inks of pen are used. In my opinion, this is ok but many students are given incident reports because of wrong inks. I admit that I am one of those students. It was in the month of September when I got my first incident report. The Medical Intensive Care Unit was transferred temporarily in the room 233 in the pedia ward. A patient died that night. When I saw the wife of the one who died, I can feel the sorrow in her heart. My heart rate had increased and I don't know why my hands and feet were trembling. This event happened during the 3-11 shift. At the time when I need to chart, I didn't' realized that the ballpen I was holding was a black ballpen but not a blue pen. Thanks to my groupmate, I only have written a sentence using a black ink. But, I got 8 hours of extension because of this. At present, I realized the need of using different inks of pen in charting. The patient's chart is a legal document so student nurses like me should take care of it. Following the guidelines of a certain hospital will lead me to be a successful nurse someday. The use of different inks in charting is very vital in saving lives of a patient.

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