Published
I find myself using the majority of the chart. There is:
orders
progress notes (from dr's, rn's, pt/ot, nutrition, and any other multidisciplinary team involved)
graphics (I&O, vital signs, labs)
MAR, meds
H&P, I tend to glance over this if it is my first time with the pt
Records from outside facilities, well I don't use this part of the chart much
Consults, where notes from other md's that are writing their initial consulting recommendations to the primary team would go
Oh and
Discharge paperwork, always important
newbiekenobe
12 Posts
Hello, can you tell me the sections of a patients chart?
And then the parts nurses would have to deal with? Why?
Thank you expert nurses i'm newbiekenobe