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It is said that it cannot be simplified at will; (3) Arabic numerals should be used for numerals with quantifiers, and Chinese characters or the mixture of Chinese characters and Arabic numerals cannot be used; ④ Drugs can be written with chemical names or trade names, and cannot be replaced by chemical molecular formulas; (5) The recorder's name should be written in full name and position, so the patient's relatives should indicate the relationship with the patient. For example, the head nurse should write ×××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××××
(2) Signing and signing (1) Signing points of nurses on duty: nurses on duty are responsible for all nursing work during the shift, carefully observe the patient's situation when taking over, and record the signature; During the shift change, every time 1 operation is made, or the patient's condition is observed according to the requirements of nursing level and the condition, it needs to be recorded and signed; Summarize and record the patient's condition before handover and sign it; Make 12 hours 1 summary records and sign them, and make 1 summary records and sign them every 24 hours.
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Name; Seriously ill patients should write a summary and sign it, and patients should write a death summary and sign it after death. ② Signing points of nurses in internship or probation period: The nursing records and signatures written by nurses in internship or probation period are the same as those of nurses on duty, but they should be reviewed by the teaching nurses and signed by them. Specific writing: name of intern nurse/name of teaching nurse. ③ Key points for the head nurse to check and sign: The head nurse is responsible for the quality of general nursing work and nursing documents, and should check, guide and sign the nursing work and records of critically ill patients every day; Check and sign the medical records of seriously ill patients and dead patients.
(3) the method of correcting writing errors. When there are typos or clerical errors in writing nursing records, nurses should not cover up or remove the original handwriting by pasting, smearing and redrawing, but should draw double horizontal lines in the wrong place, write the correct words in the upper right, indicate the date of revision and sign. Nurses use blue
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Black pen, the head nurse corrected it with red pen. There are 2 modifications per page, and the page should be copied again if there are more than 3.
(4) Time requirements for recording. The starting time of each record shall include year, month, day, hour and minute; Continuously record the changes of illness and the time of treatment; The same time can be omitted in the document of 1 page. For example, the patient was admitted to the hospital in xx years, which has been stated in the first record. If there is no record beyond this time limit, xx years can be omitted, and the writing requirements of the month and day are consistent with the year.
5] Number of records: Nurses should pay attention to the writing of nursing records, form a good habit of recording in time after work, and avoid missing or making up records. Specific requirements: ① After the succession, the patient's condition should be recorded when inquiring and checking the patient; (2) before the succession to summarize the dynamic changes of the patient's condition and main
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Nursing measures, effects and problems needing special explanation and attention; ③ Record the patient's chief complaint, discomfort, condition change, special examination, treatment and disposal, medication, pre-and post-operation situation and family conversation at any time; (4) Even when the critically ill patients' condition is relatively stable, they should be inspected every 15 ~ 30 minutes/time according to the first-class nursing standard; ⑤ In general, the nursing records of critically ill patients are recorded in real time. However, when the condition suddenly changes and the patient has an accident, the records affected by the rescue should be truthfully supplemented and marked within 6 hours after the rescue.
2. Content requirements of records
(1) Accurate content: The nursing record should accurately record the patient's chief complaint, changes of illness and signs, and there should be no vague and ambiguous descriptions, such as hypotension and excessive bleeding.
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Adjust the number of dopamine drops, etc. , should write down the blood pressure value, blood loss,
The number of drops per minute and the dosage and unit of intravenous infusion of drugs. For example, the description of the patient's consciousness should specifically include sobriety, vagueness, lethargy, shallow coma and deep coma.
⑵ Complete record: completeness means that everything recorded must have a cause, a process and a result. If the condition changes, it should reflect the cause, time, clinical manifestations, diagnosis and analysis, specific treatment and results of the condition; Staff should write down the specific time, location, name, content, etc. during rounds, rescues and operations. And there is a beginning and an end, and there is a cause and a result. If the patient complains of headache, then the perfect observation, inquiry, examination and treatment should be written as follows: The patient begins to feel persistent stuffy pain on the top of his head in the morning, measure his blood pressure 160/ 100mmhg, and report it to the doctor.
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Nifedipine 10mg was taken sublingually to observe the changes of blood pressure. Description: 10: 00 The patient's heartbeat and breathing stopped suddenly when he went to the toilet with the help of his family. 10: 0 1 The nurse on duty rushed to the ward to check that the patient's heartbeat and breathing had stopped, and urgently called the doctor to the scene for rescue. At the same time, he immediately gave the patient oxygen and continued chest compressions. But the nursing record says "the patient is weak, breathing slowly, blood pressure drops, etc." Failure to explain clearly the actual situation that the patient's condition changes when he gets out of bed and goes to the toilet may affect the doctor's judgment and treatment of the condition changes.
(4) Accurate time sequence: The contents of nursing records should record each operation separately according to the time sequence of operation completion, and there should be no record of completing multiple operations at the same time. Such as 14: 00 oral and urethral nursing, disinfection and replacement of trachea.
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Pad, disinfect tracheal catheter. The correct records should be: 14: 00 disinfection of tracheal tube, replacement of tracheal pad, 14: 10 oral care, 14: 20 urethral opening care.
5. Continuous recording of key diseases: Nursing records should dynamically reflect patients' vital signs, especially focusing on observing and recording abnormal changes of vital signs until they return to normal. For example, at 17: 30, the patient has a fever with a body temperature of 39.3℃. If physical cooling is given, the change of body temperature after half an hour should be recorded, and the body temperature should be taken as the key observation record in the small night shift and the big night shift. [6] Consistency with other records: In clinical work, it is impossible to require nursing records to be completely consistent with doctors' medical records in terms of words, expressions and punctuation. , but specific to each patient, the change and judgment of the condition, treatment medication and time-related records can not be contradictory. If the doctor's advice is intermittent oxygen inhalation, nursing records should be written.
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Continuous oxygen inhalation; At the same time, the doctor wrote that the patient stopped breathing during the course of the disease, and the nursing record wrote cardiac arrest and breathing for 5/ minute. This situation is very inappropriate and should be eliminated clinically.
Zhou Yinglan, Nursing Department of Luquan County People's Hospital
Xx year 10 year1October 9th.
The second part: writing points of nursing records of critically ill patients.
The nursing record of critically ill patients is an objective record of nurses' medical care process for hospitalized critically ill patients, and it is also an important record and legal voucher to record patients' clinical rescue and medical care at the first time. At present, there are many new members of the hospital nursing team, and the staff flow frequently, so it is necessary to know how to write correctly.
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Discussion and training of nursing records for critically ill patients. The writing points of patient care records are summarized as follows:
Defect analysis:
1. The time recorded in intensive care is inconsistent with the doctor's advice.
When a nurse accepts a critically ill patient, she immediately takes routine first-aid measures such as oxygen inhalation, sputum aspiration, venipuncture and ECG monitoring according to her condition. However, doctors only prescribe medical orders after physical examination, which leads to the time of nursing records earlier than the time when doctors prescribe medical orders.
2. The contents of the first intensive care record were incomplete ① Nurses were too busy to ask about their illness, especially at night shift, and only 1 nurse was on duty. (2) Nurses only pay attention to the patients' observation records when they are admitted to the hospital, and
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Ignoring the inquiry about the cause and change of the disease before admission. ③ Most nurses can't make a comprehensive analysis of patients' complaints, so they copy doctors' complaints. ④ Some nurses didn't master the methods of collecting medical history, and their language skills were lacking, which led to incomplete collection of medical history.
3. The contents of critical illness records are simple and cannot reflect the characteristics of medical history. ① Observe the condition carelessly, simply describe the symptoms of the condition, or copy the record of the last class, the nursing content is the same, and the focus is not prominent. For example, "the condition is the same as before, and there is no special change." (2) Used for logging. Even if the changes of the disease are observed, they cannot be expressed because of the lack of experience in specialist theory. For example, only "shortness of breath" was recorded, and it was not further described whether the performance of shortness of breath was regular, whether there was a flap of the nose, whether there was a nodding breath or a concave sign.
4. Subjective judgment is more than objective record.
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① After taking medicine or physical cooling, patients with high fever record "gradual decrease of body temperature" and do not measure their body temperature. ② The description of "stable condition" often appears in night shift records.
5. The record of the rescue process is inconsistent with the doctor's medical record.
When rescuing critically ill patients, nurses only pay attention to the implementation of treatment and nursing measures, especially when the rescue time is long, they only record the beginning and final results, ignoring the records of the rescue process, which makes the rescue records pale and powerless, unable to truly reflect the whole rescue process and unable to safeguard the legitimate rights and interests of both nurses and patients. Young nurses are the best.
6. The intensive care record is inconsistent with the nursing plan.
When making intensive care plan, nurses mostly copy textbooks and write them carefully. But don't consider whether it can be realized.
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These nursing plans have caused the serious disconnection between nursing records and nursing plans, and lost the significance of nursing plans. For example, the ward temperature in the nursing plan is controlled at 18℃ ~ 20℃ and the humidity is 50% ~ 60%. General hospitals can't meet this standard. Another example is "oral care twice a day" for patients with high fever. But when there is no oral health care doctor's advice, it will not be implemented.
7. There is no effect evaluation after taking nursing measures.
For example, "patients with abdominal distension are given gastrointestinal decompression", and whether abdominal distension is relieved after gastrointestinal decompression is not recorded. Patients with heart failure did not record their urine volume in time after using diuretics.
8. Lack of summary and evaluation records of illness.
According to the regulations of intensive care records, nurses should make two overall evaluation records of their illness after taking over and before handing over.
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But some nurses missed any link in this link, and even if they did, the record was incomplete.
9. Lack of observation records of complications.
For example. Severe pneumonia only pays attention to the observation of the symptoms of pneumonia itself, and there is no observation record of complicated heart failure, which can not provide doctors with the basis for early diagnosis and treatment of heart failure.
Countermeasures:
1, strengthen the study of specialized theoretical knowledge ① require nurses to memorize the clinical manifestations and nursing routines of common diseases in their undergraduate departments. (2) The head nurse asked the nurses in the form of early class meeting and nursing rounds to understand their mastery of theoretical knowledge of this major. Departments conduct 1 theoretical knowledge examination every month, which can test the clinical manifestations and nursing routine of a disease.
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2, strictly abide by the writing principle of critical illness records, so that the records are timely, accurate and true (1) In order to keep the time of critical illness records consistent with the doctor's advice, nurses should communicate with doctors at any time, observe the time of illness changes consistent with the time of implementing emergency nursing measures, and consistent with the rescue content recorded by doctors. (2) Record all contents of nursing measures in time to prevent missing items. Such as "oral care, skin care, etc." . (3) Inform the doctor immediately when the condition changes and take timely treatment and nursing measures.
3. Improve the writing ability of nurses to observe the condition, pay attention to records and overall evaluation.
4. Nurses should master the correct method of collecting medical history.
General requirements of nursing records:
(1) written in strict accordance with the relevant provisions. (2) Signature and trial signing.
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① Key points of signature of nurses on duty. The nurse on duty is responsible for all nursing work during the shift, carefully observing the patient's situation when taking over, and recording and signing; During the shift change, every time 1 operation is made, or the patient's condition is observed according to the requirements of nursing level and the condition, it needs to be recorded and signed; Summarize and record the patient's condition before handover and sign it; Make a summary record of 1 and sign it every 24 hours; Patients who stop special and first-class care should write a summary and sign it, and patients should write a death summary and sign it after death.
② Signing points of nurses in internship or probation period: The nursing records and signatures written by nurses in internship or probation period are the same as those of nurses on duty, but they should be reviewed by teaching nurses and signed before signing. Specific writing: name of teaching nurse/name of practice nurse.
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(3) the head nurse audit signature points. The head nurse is responsible for the quality of general nursing work and nursing documents, and checks, guides and signs the nursing work and records of critically ill patients every day.
(3) Correcting methods of writing errors
When there are typos or clerical errors in writing nursing records, nurses should not cover up or remove the original handwriting by pasting, smearing and redrawing, but should draw double horizontal lines in the wrong place, write the correct words in the upper right, indicate the date of revision and sign. There are 2 modifications per page, and the page should be copied again if there are more than 3.
(4) Time requirements for recording
The starting time of each record shall include year, month, day, hour and minute; Continuously record the changes of illness and the time of corpse.
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Arrival point; The same time can be omitted in the document of 1 page. For example, the patient was admitted to the hospital in xx years, which has been stated in the first record. Records that do not exceed this time limit can be omitted in xx years.
5] Number of records required
Nurses should pay attention to the writing of nursing records, form a good habit of recording in time after work, and avoid missing or making up records. The specific requirements are as follows: ① After the succession, the patient's condition should be recorded when inquiring and checking the patient.