[Internal Medicine Nursing Paper] Nurses with legal internship qualifications objectively record the nursing process of patients during hospitalization according to the doctor's advice and illness: 1. Understand the meaning and requirements of the doctor's orders one by one, and answer the implementation and results of each doctor's order. Inquire about improper, unclear and unclear doctor's orders in time to avoid taking direct responsibility for mistakes. 2. Taking the illness and doctor's advice as the main record, reflecting the routine contents of professional nursing at the same time, and communicating with doctors in time to maintain consistency with doctor's advice, not only have positive performance, but also have important negative performance. 3. According to the condition, doctor's advice and nursing routine, the method of "problem-treatment-effect" was adopted to record; For the problem, keep dynamic and continuous, don't interrupt. 4, record content description should be objective, specific, true and timely, don't casually write subjective inferential language, conclusive language and general language, no nursing diagnosis and related factor analysis. Use medical terms. 5. Don't use descriptive taboos: for example, tell the doctor that the patient is untreated, the condition is stable (especially for critically ill patients), drink more water, the effect is to be observed, the patient is to be observed, and then the observation is general, fair, re-observation, morning care, intracardiac massage, kidney adjustment, refreshing, smooth infusion, acid correction, and the patient is not in the ward (for no reason). 6. "Eight Attention": Pay attention to the improvement of professional knowledge and ability (medical knowledge, nursing routine, operating norms, etc. ); Pay attention to the patient's chief complaint, request, condition change and occurrence time; Pay attention to the dignity of doctor's advice and strictly record the time, content, execution time and effect of doctor's advice; Pay attention to record the time, object, event and result of the event report in a timely and appropriate manner (in a notebook if necessary); Pay attention to possible dangers, disputes and incidents, and make records in time (prepare notebooks if necessary); Pay attention to the patient's "informed consent right", explain it in place before, during and after treatment, and record it; Pay attention to the seriousness of signature; Pay attention to the consistency of records and medical records in time and content. 7, do not alter, two typos, one page is less than two typos, black and blue ink, abbreviations and the correct use of foreign languages, and the allergic situation is recorded in the corresponding place of the temperature record sheet with red pen. 8. When the illness changes, adjust the book according to the importance of the problem. ...