1. A nursing record sheet (general or critical) must be established for all inpatient care records.

2. The nursing record sheet must be written and fully signed by a nurse with a practicing certificate. Unlicensed personnel cannot write or sign alone. 3. The nursing record sheet written by a trainee nurse or unlicensed person must be written by a licensed nurse. After reviewing and revising the certificate, the nursing staff will sign with a slash. Those without a certificate will sign in the denominator, and those with a certificate will sign in the numerator.

4. The time should be written at the time when the writer picked up the pen and started writing. It cannot be earlier or later. It must be factual. Only write the date once in a day, and only write the specific time in other times

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