Nursing record sheet (PIO) is the core part of nursing medical records, and the process of nursing record should reflect the dynamic changes, that is, recording the PIO in the form of PIO:
It is the core part of nursing medical records, and the process of nursing records should reflect dynamic changes, that is, PIO mode should be used for recording. P- problem, I- intervention, O- result. This kind of nursing record sheet integrates the nursing plan, nursing measures, measures basis and effect evaluation in the original responsibility system nursing medical record, which is more convenient to record and write. It does not emphasize the separate list of nursing diagnosis, measures and results, but is reflected in the nursing course record. Everyone has the experience of writing responsibility nursing medical records, and writing this kind of nursing record sheet should be
Writing format: the first nursing course record is written immediately on the year, month and day, and the other blank begins to be written on the first day of hospital, describing the general situation of the patient, including psychological state and understanding of the disease. According to the priorities of the observed nursing problems, write down the nursing problems to be solved and the nursing measures to be taken that day, including the psychological state analysis and the cooperation of family members, and record the publicity and education of the people's hospital. Record another line and sign your full name on the right.
Nursing course records should avoid repeating the same nursing problems without evaluating the effect of nursing measures. It is enough to briefly record the course of the disease before the shift, especially to show that the nursing method is not just to carry out the doctor's advice.
In the process of recording, it is necessary to reflect the physical and mental changes of patients and record the contents of health education appropriately. In addition, it is necessary to reflect the nursing rounds. For example, the head nurse makes morning rounds, discusses nursing medical records, and checks the nursing quality organized by the nursing department. The nursing contents of patients should be recorded.
Nursing records should be consistent, that is, the effect evaluation of previous nursing problems may be short-term or long-term, and it should be explained according to the situation. The nursing record of the day before discharge briefly summarizes the current situation of patients, mainly to evaluate the effect of using nursing methods to make patients recover, or to state the reasons for discharge. Only in this way can the nursing record be complete.
The relevant contents of nursing records should be consistent with the medical records, and there should be no discrepancy, so as not to cause legal disputes.
PIO is the essence of holistic nursing record, which can best reflect the quality and value of nursing work and should be recorded carefully.