Book 14 · Page 1010 / 15

The Flowsheet That Says More Than the Note

Jackson-Pratt, Hemovac and Penrose drains compared by whether each is open or closed and uses suction. — Fig 15.10 · pending clinical review

EXHIBIT · MERCY GENERAL · 4 WEST · RM 412 · POSTOPERATIVE DAY 2

VITALS · INTAKE & OUTPUT · SKIN · NOTES · ORDERS

TIME	BP	METHOD	HR	RR	TEMP	ROUTE	SPO2	PROBE SITE
2000	132/78	adult cuff, R arm, sitting	88	18	98.7	oral	97%	R index
2400	134/80	adult cuff, R arm, sitting	92	18	99.1	oral	96%	R index
0400	128/76	adult cuff, R arm, supine	96	20	99.4	oral	96%	R index
0800	118/70	small cuff, L arm, supine	98	20	98.2	axillary	95%	L index
1200	116/68	small cuff, L arm, supine	102	22	98.4	axillary	95%	L index
1600	120/72	small cuff, L arm, supine	104	22	98.6	axillary	94%	L index
2000	138/84	adult cuff, R arm, sitting	104	22	99.4	oral	96%	R index
2400	136/82	adult cuff, R arm, sitting	106	22	99.6	oral	96%	R index
0400	140/86	adult cuff, R arm, sitting	108	24	99.8	oral	95%	R index

INTAKE & OUTPUT (tab legible behind)

SHIFT	URINE	DRAIN A	DRAIN B
Nights	640 mL	55 mL	30 mL
Days	520 mL	60 mL	25 mL
Evenings	410 mL	5 mL	(blank)

SKIN

Body map, sacrum: 4.5 cm by 3.2 cm area, partial-thickness, viable pink moist bed, no slough. Stage recorded as Stage 2.
Device site, left index finger under pulse oximetry probe: non-blanchable deep red discoloration of intact skin, noted this shift. ⚑

NOTES (four-line narrative entry, reproduced at reading size)

``` 0630 Pt appears anxious and is obviously in a lot of pain. Repositioned for comfort. Will continue to monitor.

0800 Sacral area reddened. Stage ▮▮▮▮▮▮▮ Stage 2. Dressing applied. 0930 Assisted with care during the night shift. Tolerated well. ```

The four defects, annotated outside the frame

DESCRIBE, DO NOT INTERPRET — "appears anxious" and "obviously in a lot of pain" are conclusions. Record what the patient said and what you observed.
NO BLANK LINES — the gap inside the entry leaves room for another author.
LATE ENTRY MUST BE LABELED WITH BOTH TIMES — the 0930 entry describes night shift care with no late entry label and no time of occurrence.
SINGLE LINE, INITIAL, DATE, NEVER OBLITERATE — the original stage was blacked out rather than struck once and initialed.

The task

Answer three questions before turning the page. Which measurement cannot be compared across these three shifts, and why? Which tab holds the evidence that a device is causing harm? Which line of the narrative note would fail a record review, and what would you have written instead?

Margin notethe chart is testimony. write it that way.

Watch outthe blood pressure trend here is an artifact. Cuff size, arm, and position all changed at 0800 and changed back at 2000, so the apparent dip and rebound is method, not physiology.

TakeawayA flowsheet with an inconsistent method column has no trend in it, and a note with a blank line has an author it cannot defend.

Measurement technique → BOOK 15 · P7. Intake and output balance math → BOOK 06 · P4.