Page 27 - INTRODUCTION OF NURSING 1.4 The Nursing Process (PART 3)

C = Complete

Include:

• Condition change

• Patient responses, especially unusual, undesired or ineffective response

• Use of chain-of-command

• Communication with patient and family

• Entries in all spaces on all relevant assessment forms

➢Use N/A or other designation for items that do not apply to your patient

➢DO NOT LEAVE BLANKS

➢Blanks are hazardous because they permit entries above your signature

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➢Others may make entries in such blanks by mistake or to purposely falsify records