NURSE'S NOTES: Obsolete terms in Nurse's Chart (Obsolete term
---> Reasons ---> Suggested Phrase)
1.Consciousand 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 fairappetite ---> 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).
