How to write the treatment plan of admission record in the intelligent health file?

Disposal scheme of admission records in intelligent health records

one

First, enter the nursing record

1, sample 1:

1- 1 1 13: 15

/kloc-turn out from the emergency department at 0/2 and push into the ward. He was diagnosed as an open fracture of his right ankle (fracture) and was infused with his right hand. Ringer group, 60g TT/min 500ml, the rest 200 ml, suffered from pain and bleeding in the right ankle for three hours due to a personal car accident. He is conscious, mentally ill, miserable, with pale tongue, thin white fur and mysterious pulse. Check the temperature of 36.8, pulse 98 times/minute, respiration 23 times/minute, blood pressure 96/56mmHg, make active preparations before and after admission, explain the precautions before and after operation to patients and their families, and give the application of anesthetic drugs before operation. /kloc-sent to the operating room at 0: 30, and has been taught to enter the department. Don't be nervous, the patients and their families understand.