what has been done for the patient. The record must be
written; otherwise details cannot be remembered exactly. It should be as
simple and concise as possible; it is the place for facts, not for
opinions, and if inaccurate it is worse than none. It is better not to
keep the record in the patient's room, for the patient should not see
his own record, nor hear its contents discussed. The doctor usually
writes his orders on the record sheet itself, or on a separate sheet to
be attached to the record for reference. Blank record forms can be
purchased, but a form that is made at home is entirely satisfactory. An
example of a daily record sheet follows.
RECORD
------+----------+----+-----+-----+----------------+----+-----+-------
Date | Hour |Tem.|Pulse|Resp.| Diet and |B.M.|Urine|Remarks
| | | | | medicine | | |
------+----------+----+-----+-----+----------------+----+-----+-------
1916 | | | | | | | |
Jan. 1|4 p.m. |100 | 76 | 24 |Medicine | | |
|5 p.m. | | | | | 1 |oz. |
| | | | | | |vii |
|6 p.m. | | | |Supper: | | |
| | | | | Baked potato, | | |
| | | | | toast, fruit, | | |
| | | | | tea. | | |
|8 p.m. | | | |Medicine | | |Sponge
| | | | | | | |bath.
|9:30 p.m. | | | | | | |Asleep.
Jan. 2|3 a.m. | | | | | |oz. |
| | | | | | |ix |
|8 a.m. |99 | 74 | 22 |Medicine | | |Patient
| | | | | | | |slept
| | | | | | | |most
| | | | | | | |of the
| | | | | | | |night.
|8:30 a.m. | | | |Breakfast: | | |
| | | | | Cereal, orange,| | |
| | | | | toast, coffee. | | |
|9:30 a.m. | | | |Bath.
|