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).