The nursing chart, observations and handover

Every dose of the round on time, observations and the early warning score, and the shift handover.

Medicines due: doses in the next two hours and those late; given, refused or held (with the reason).
Scan the patient’s card or ID before giving — required if the hospital says so.
A controlled medicine asks how much was used, what was thrown away and a witness — written in the chart and the register together.
Observations: BP, pulse, breathing, SpO₂, temperature, consciousness; a high early warning score tells the doctors.
Handover: drafted from the chart, taken over by the next shift.

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