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Course Intro: Nursing Rules, Medical Reporting & Recording

A Introduction to the basic nursing rules, regulations, rights, and laws. You will also see how to properly  record measurements including time.


Basic Rules of Conduct

  • Respect other people as individuals.
  • Follow instruction of your charge nurse to the best of your ability.
  • Do NOT perform tasks that are not within your legal limits.
  • Do NOT perform any tasks you are not prepared to do.
  • Protect the person’s privacy at all times.
  • Keep information regarding patient confidential at all times.
  • When assisting patients, keep them covered at all times.
  • If a visitor is in the room, kindly ask them to step out.
  • Never open patients mail.
  • Never discuss the patients care with other team members, family, or anyone except the charge nurse.
  • Always allow the patient privacy when asked.

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The Never Never Rules:

  • Never give drugs.
  • Never do a job beyond your legal limits.
  • Never insert tubes/objects in to body openings. DO NOT remove them from the body.
  • Never take a phone or oral order. Grab the nurse in charge to take the order.
  • Never perform procedures that require “STERILE” techniques. You can assist a nurse if asked, but don’t perform.
  • Never tell a person or family a diagnosis, condition, surgical plan, or any treatment plans.
  • Never Diagnose or tell someone what to take for medications.
  • Never supervise other nurses assistants, your not trained too.
  • Never ignore order/request to do something. This only includes tasks your are allowed to do by law. If you can’t politely notify the nurse.

    Legal Aspects:

    Examples of abuse are and is note limited to unclean or unsafe living conditions, significant weight loss, missing equipment, medication not properly administered, pressure ulcers (Bed Sores).  If you do notice any of these signs notify the nurse. If these things go un-looked you could be held legally responsible.

    Patient Rights and legal issues:
    Never except any money or any items as gratitude (Tips or thank you presents) from the patient. Explain to them that you appreciate the thought but you legally can’t take it.

    Professional Sexual Misconduct

    Never touch a patient in a sexual manner even if the patient consents never conduct sexual activity. If preforming a task near the genitals, do so in a professional manner and explain what you are doing (inprofessional terms).

    Boundary Crossing

    Brief acts or behaviors not helpful. This can be intentional or unintentional.
    Ex: hugging a crying patient. Only do this if it meets thier personal needs and not your own.

    Negligence by a professional person that creates harm to a person.


    Working in another stateIt is up to you to find out the other states requirements and for you to comply.

    Reporting & Recording

    Reporting is the oral account of care and observations. You report care and observations to the nurse when:

    • Any change in condition.
    • When you leave for breaks/meals.
    • Before end of shift

    Tips for reporting:

    • When reporting, give person’s full name, room number, and bed number.
    • What you observed and time of observation.
    • Report only what you observed, or did yourself.

    Recording is the written account of care and observations.


    • Always use ink.
    • Always use your name and title when you record. It is important that you use patients full name, room number, etc.
    • Don’t skip lines
    • Always make sure your recording the right patient.

    Recording Time:

    You will most always record time in 24 hour clock/military time. The following is a conversion.


     Regular Time
     24/Military Time
    2am  0200
     3am  0300
     4am 0400
     5am 0500
     6am 0600
     7am 0700
     8am 0800
     9am 0900
     10am 1000
     11am  1100
     12 noon
     2pm  1400
     3pm  1500
     4pm  1600
     5pm  1700
     6pm 1800
     7pm 1900
    12 Midnight

    To add what minute it is put the minutes where the 0’s are: For example 4:32pm would be 1632 in 24 hour clock/military time.

    Nutrtion and Fluids


    the most important nutrient. It is needed for tissue growth and repair. Sources include: meat, fish, poultry, eggs, milk, and milk products, cereals, beans, peas, and nuts.

    Provide energy and fiber for bowel elimination.

    Provide energy, they add flavor to food and help the body use certain vitamins.

    are needed for certain body functions. They don’t provide calories. The body stores vitamins A, D, E & K.

    are used for body processes needed for bone and teeth formation, nerve and muscle function, fluid balance and other processes.

    is needed for all body processes.


    Doctors may order spacial diets for patients.


    1. Sodium Controlled – daily sodium of 3000 to 5000 mg.
    2. Diabetes Meal Plan – For people with diabetes.
    3. Dysphaga Diet – The doctor, speech therapist, or occupational therapist choose right thickness. This is for someone who has difficulty swallowing.


    Normal Fluid Requirements
    Adults need 1500ml of water daily to survive. About 2000 to 2500ml of fluid is needed for normal fluid balance.

    Special Fluid Orders

    1. Encourage Fluids- Encourage patient to drink, increase amount of fluids.
    2. Restrict Fluids- fluids are limited to certain amount set by doctor.
    3. Nothing by mouth (NPO) – Person cannot eat or drink by mouth.
    4. Thickened Liquids – All fluids are thickened, including water.

    Caring for the Person

    • Always address person by name.
    • Never call them by their first name, unless they instruct you.
    • Don’t use names like: Honey, sweetie, or grandma.

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