You have finished your client's charting for the shift that is the end of the 24-hour period and the bottom half of the page remains blank. What is the generally accepted action to take?
1. Draw an X through the remainder of the page.
2. Do nothing since you do not have further notes on the client's care.
3. This is not an issue because charting is not separated by days.
4. Draw a single line through the remainder of the page.
Question 2
While you (M. Tom, RN) were at lunch, another nurse (C. Lu, RN) charted the prn medication C. Lu gave to your client. You had not charted that you changed the client's dressing. Of the following charting entries, which would be most appropriate?
1. 11:20 a.m. prn med given as ordered. C. Lu, RN; 12:00 noon Abdominal dressing changed at 10:30 a.m. per Dr. Su. Suture line intact with serosanguineous drainage noted at proximal edge. M. Tom, RN
2. 11:20 a.m. prn med given as ordered. C. Lu, RN; No need to chart dressing change since there were no signs of infection or bleeding.
3. 10:30 a.m. Abdominal dressing changed per Dr. Su. Suture line intact with serosanguineous drainage noted at proximal edge. M. Tom, RN prior to the 11:20 a.m. prn med given as ordered. C. Lu, RN entry.
4. 11:20 a.m. prn med given as ordered C. Lu, RN; 12:00 noon Addendum 10:30 a.m. Abdominal dressing changed per Dr. Su. Suture line intact with serosanguineous drainage noted at proximal edge. M. Tom, RN
An example of SOAP charting.
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