Progression and D/C Notes

Question 1

4 legalities you need in progression notes

Answer 1

• Legible
• Sign name, role (e.g RN) date and time
• Black pen
• Cross out errors and sign them off
• Don’t do leave any gaps, make sure to cross them off.

Question 2

Why you may not be able to finish a d/c notes

Answer 2

• May be out of your scope of practice, when this happens refer to someone who’s position is higher than you, e.g a manager or refer to hospital policy.