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Talking about how to instruct nursing students to write nursing medical records.
Editor's Note: Nursing paper is a kind of scientific paper, which is an argumentative paper used to carry out nursing scientific research and describe the research results. Paper net provides you with the reference of model nursing papers, as well as the paper writing guidance and format requirements, to solve your problems in paper writing. Keywords practical nursing students; Nursing medical records; Holistic nursing In order to better adapt nursing students to the development of holistic nursing work and cultivate practical nursing staff, nursing students will gradually enter the role of holistic nursing through education, training and clinical implementation, which requires teachers to guide nursing students to learn to write nursing medical records. Now let me talk about my specific practice. 1 require nursing students to learn the nursing concept formulated by our department, so that students can understand that systematic holistic nursing requires nurses to provide all-round care for patients in charge, and take patients as the center to provide basic care, internal medicine care, rehabilitation care and psychological care for patients. 2. Understand the relationship between forms used in clinical systematic holistic nursing and nursing procedures. Nursing procedure is a systematic and planned nursing work process, taking measures and changing measures according to the development and change of illness, and applying multidisciplinary knowledge to deal with patients' diseases and health problems. The basic steps can be divided into estimation, diagnosis, planning, implementation and evaluation. The relationship with the form is: nursing evaluation: the first evaluation when the patient is admitted to hospital and the daily evaluation when the patient is admitted to hospital. "Nursing diagnosis: nursing diagnosis-list of questions. Nursing plan: expected effect, standard nursing plan and standard education plan. Implementing nursing plan: nursing records. % evaluation result: nursing record. 3 imitate the writing of learning nursing form. Writing nursing forms is an important part of recording nursing procedures. The patient's condition is constantly changing, and the nursing diagnosis and nursing measures are changed at any time and recorded on the nursing record sheet. The nursing department of our hospital has worked out various nursing forms according to the nursing procedures, including: patient admission evaluation form (general information; Medical related materials; Life, psychology and society; Nursing physical examination). List of nursing diagnosis questions. Nursing record form, that is, nursing diagnosis, that is, nursing measures, that is, nursing evaluation. Discharge evaluation form. Nursing students who have just entered clinical practice have read so many forms that they don't know how to fill them out. Teachers need to explain the forms one by one, how to collect information, how to find nursing diagnosis or nursing problems, and how to evaluate the effect. And take out the perfect nursing medical records for the reference of nursing students, so that students can be familiar with the writing of nursing forms. 4. Clinical practice guides nursing students to complete nursing medical records. The implementation of holistic nursing not only requires nurses to be sympathetic, amiable, serious and responsible, skilled, but also needs rich medical knowledge. Therefore, the implementation of holistic nursing should do the following: strengthen basic nursing and life nursing, keep the ward clean, quiet and comfortable, and meet the needs of patients. " Implement standardized health education for patients, that is, educate patients on disease awareness, prevention and health care in view of their lack of knowledge. In the process of implementing holistic nursing, timely evaluation and working methods were made to improve work efficiency and nursing quality. Encourage nursing students to learn professional ethics, psychology, professional medical knowledge, basic nursing theory and new technology and new business. Through example teaching and clinical practice, nursing students gradually have the ability to implement nursing procedures and independently complete complete nursing medical records, thus entering the overall nursing role.