Analysis of medical quality in obstetrics and gynecology in 2007. The workload increased: 1, and the number of outpatients increased (June-April 2006 24742; 1~ April 2007, 30942); The amount of treatment in wards and the number of surgical cases have increased. 2, the number of disputes decreased (in 2006, 1 1; 1~ April 2007, 3 cases); The average length of stay decreased (8.35 days ↘7.40 days in gynecology; Obstetrics 5.00 days ↘4.96 days) bed utilization rate increased (gynecology104.7% ↗105%; Obstetrics 1 07.7%138.5%) Second, the current problem:1. Reasons for medical insurance cost overrun: (1) Medical insurance patients were transferred to specialized hospitals, and the cost of examination and treatment increased. (2) There are more and more laparoscopic operations. (3) The disease index of medical insurance policy is low. Rational use of antibiotics (2) reduction of unnecessary expenses (3) improvement of medical insurance single disease index as appropriate. 2. There are many departments in obstetrics and gynecology, and the personnel are scattered. 3. The workload has obviously increased (1). There are many doctors who can further their studies. 2. There are many departments and limited personnel. 3. Mobilize employees' enthusiasm to ensure medical quality. 4. The staff in B-ultrasound room (1) are in urgent need. 5. There is no colposcopy and liquid-based cytology (TCT) examination in outpatient department, and many patients are lost, which is prone to medical disputes. 6. Adjust the layout to cope with the baby boom (1) and increase the number of beds (2) Strengthen the management of medical personnel to ensure the quality of medical care; 3. Nurses: 1, aging and facing retirement; 2. Strong professionalism and strong talent training cycle; 3. Obstetrics has 13 nurses, which is difficult to meet the growing demand. 4. Obstetric space is narrow and facilities are outdated. Iv. Issues requiring coordination among various departments: 1. The pathological report of pathology department has been rejected many times, which has affected the quality and efficiency of clinical work. 2. Blood supply in blood transfusion department is late, and platelets are kept for a long time, so it is often difficult to rescue critically ill patients in obstetric emergency. 3. The waiting time of patients undergoing elective surgery is long, which affects the satisfaction rate. 4. There is no charge on the 7th floor of the outpatient clinic on Saturday, and the patient travels back and forth from the 2nd floor to the 7th floor for many times, resulting in great opinions and disputes. 5. After Friday and Saturday 1 1:30, the hospitalized patients did not have ECG and chest X-ray examination. Patients have long waiting time and long hospitalization days. 6. copier problem. I hope to inform you by fax or in writing, because mobile phone messages are sometimes not received, sometimes received late, or even expired.
Verb (abbreviation of verb) feedback rectification 1. There is no charge on Saturday at the 7th floor of the outpatient department: through the coordination of the outpatient department, the problem has been solved, and this Saturday will be implemented from July 7th, 2007. 2. Gynecological emergency clinic should be equipped with stethoscope and sphygmomanometer: the clinic has vertical sphygmomanometer. 3. Suggestion: develop diversified forums to strengthen communication between doctors and patients; For the development of hospitals and disciplines, the treatment and nursing of newborns can not be ignored. Please continue to pay attention to China Nursing Network! We will serve you wholeheartedly! Model essay on nursing rounds record-how to write nursing rounds records for patients with mental perception disorders. General nursing for mental perception disorders will put patients in intensive care unit to check whether there are removable dentures in their mouths. If you have false teeth, you should take them off. Patients should try to avoid wearing glasses to prevent falling and injury. Strengthen patrols to detect seizures in time. Take necessary measures to avoid inducing factors. Inducing factors include excessive drinking, eating, drinking, constipation, poor sleep, emotional excitement, stuffy air, strong sound and light stimulation, and sudden cessation of taking antiepileptic drugs. Pay attention to the condition. When the patient complains of chest tightness, numbness of limbs, bad smell, mood changes and hallucinations, immediately put the patient on his back and prepare for sudden unconsciousness. Encourage patients to develop good living habits, work and rest regularly, defecate, avoid constipation and overwork, eat lightly, and reduce strong light stimulation. Seriously implement drug treatment requirements and nursing routine. Observe the drug reaction, give the medicine according to the doctor's advice on time, and ensure that the patient will take the medicine. Pay attention to the side effects after taking the medicine. Including whether there is ataxia, lethargy and dizziness. Don't stop taking medicine or changing medicine suddenly. So as not to induce epilepsy. Family support, patients should visit frequently during hospitalization, so that patients can enjoy the warmth of family. Patients' home care should pay attention to urge patients to take medicine, care about the changes of patients' condition, reduce the stimulation to patients and prevent the recurrence of their condition. Symptomatic nursing: grand mal nursing: 1. Let the patient lie on his back and quickly put the dental pad between the upper and lower molars in the mouth to prevent biting his lips and tongue. In case of emergency, horns and towels can be used instead, but be careful not to fill the whole mouth, so as not to affect the collection and arrangement of respiratory medicine education network. 2. Loosen the collar button and belt. Protect mandible and limbs. 3. Turn the patient's head to one side after the convulsion stops to prevent saliva from being inhaled into the trachea by mistake. 4. Observe the recovery of breathing. If the respiratory recovery is not smooth and the face is cyanotic, artificial respiration should be performed immediately, oxygen should be given, and respiratory stimulants should be used if necessary. 5, check whether there is any fracture and dislocation in patients, patients in bed rest, specialist care.
Protect patients from falling. Continue to observe whether the patient has signs of persistent attacks. Incontinence patients change clothes and pants in time. Nursing care of status epilepticus: If convulsion persists, it often leads to circulatory failure, respiratory disorder and electrolyte disorder, which is life-threatening. The attack should be stopped immediately. In the process of cooperating with the rescue, the nurse should do: 1, nurse by special person, closely observe the condition, record the frequency of attack in detail, the duration and interval of each attack, and pay attention to the changes of vital signs. 2, keep the respiratory tract unobstructed, prevent hypoxia. Turn the patient's head to one side to facilitate the discharge of oral secretions, suck sputum at any time, and do artificial respiration in time when breathing difficulties are found. 3. Patients with high fever should be given physical cooling. 4. Ensure the implementation of treatment. 5. Protect limbs and do basic nursing. 6. After 24 hours of seizure control, mixed milk can be fed by nose according to the patient's consciousness. What are the classifications of nursing rounds? 1. According to the nature of ward rounds, it is divided into clinical professional ward rounds, teaching guidance ward rounds and routine evaluation ward rounds. Clinical ward round is a nursing ward round with rare clinical cases, particularly critical cases, complicated major operations, new businesses and technologies, special examinations, problems often encountered in nursing work and experiences and lessons learned in work as the main contents. There are two kinds of teaching guidance rounds: one is the nursing rounds organized by the teaching teacher according to the syllabus of the school where the nursing students are located; The other is the nursing rounds organized by the head nurse or the nursing department, which are attended by clinical nurses and focus on selecting a disease or problem from the clinical business rounds. Routine evaluation rounds are nursing rounds with the implementation of nursing measures, nursing effects and other nursing procedures as the main contents, in order to improve nursing methods and improve nursing quality. 2。 According to the nursing level, it is divided into nurse group leader rounds, head nurse rounds and nursing department rounds. In systematic holistic nursing, ward nurses are divided into clinical nurses, head nurses and head nurses. Using nursing procedures to carry out graded nursing rounds can give full play to the technical advantages of nurses with different energy levels and play their respective roles. Clinically, special nursing rounds should belong to clinical professional rounds. The form of ward rounds mostly uses the content of nursing degree to carry out special ward rounds. The content of rounds is mainly specialized nursing knowledge. Ordinary care record sheet writing sample nursing record is the nurse's reflection on the patient's vital signs, and it is the concrete embodiment of the implementation of various medical measures and the record of its results in the process of medical nursing activities. (3) Nursing physical examination: such as temperature, pulse, respiration, blood pressure, weight, consciousness, expression, general nutrition, skin and mucosa, physical activity, allergic history, psychological state, etc. (4) Living habits: such as diet, sleep, defecation habits, hobbies, etc.
This nursing sheet integrates nursing plan, nursing measures, measures basis and effect evaluation, which is more convenient to record. In the process of writing, it is not necessary to list the nursing diagnosis, measures and results separately, but it is reflected in the nursing course record, as follows: (1) Nursing record is an objective record of the nursing process of patients during hospitalization according to the doctor's advice and illness, so as to avoid repeating the same nursing problems without the effect evaluation of nursing measures. According to the patient's condition, record the patient's conscious symptoms, emotions, psychology, diet, sleep, defecation and defecation, as well as the new symptoms and signs of the patient. Seriously and truthfully record the treatment measures implemented according to the condition, the effect after the implementation of nursing measures and adverse reactions. (2) Record the positive results of laboratory examination so as to observe the condition, but don't record the contents of subjective analysis. (4) Pay attention to vital signs. If the doctor fails to give treatment advice when the patient has symptoms and asks for "observation", "observation" is also a doctor's order. The nurse should record the doctor's full name and the contents of the doctor's orders. (5) On the day of discharge or before discharge 1 day, the patient's condition, prognosis and health problems that need to be explained to patients and their families should be clearly stated. (6) Before the operation 1 day, the patient's preoperative preparation should be recorded, and whether the condition has changed; Records should be made in time on the day of operation, and at least 1 time should be recorded in each shift in the first three days after operation, and the changes of the condition should be recorded at any time. On the day of discharge, record the postoperative wound of the surgical patient, whether there is a drainage tube, whether there is a suture removal, and the contents of health education and guidance that need to be explained to the patient and his family. 3 Discharge instruction The discharge instruction was written before the patient was discharged 1 day in duplicate (one copy was taken away by the patient). According to patients' different diseases, psychology, treatment and nursing conditions and living habits, the guidance contents include diet, rest, medication, reexamination, preventive health care knowledge and related matters needing attention. Try to be specific, don't just write principled words, it should vary from person to person, and it can't be stereotyped. 4 Matters needing attention in writing nursing records (1) Writing format: write the year, month and day at the beginning of the first nursing course record, and start writing the first day of the patient's admission in another blank space, describing the general situation of the patient, including the psychological state and the degree of 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. Record another line and sign your full name on the right. (2) In the process of nursing, it is necessary to avoid repeatedly recording the same nursing problems without evaluating the effect of nursing measures.
It is necessary to embody more nursing methods, not just to follow the doctor's advice. (3) The changes in patients' mind and body should be reflected in the process of nursing records, and the contents of health education should be recorded appropriately. In addition, it is necessary to accurately record nursing rounds, nursing case discussions and patient care contents. (4) Nursing records should be consistent, that is, the effect evaluation of some previous nursing problems may be short-term or long-term, and the reasons should be explained according to the situation. (5) The related contents of nursing records should be consistent with the medical records, and there should be no discrepancy, so as not to cause legal disputes. (6) When writing nursing medical records, the head nurse should make an overall arrangement, reasonably divide the work, select experienced senior nurses to write, and the head nurse should give guidance to ensure the quality of medical records. (7) The nursing process of critically ill and rescued patients should be recorded at any time, and ordinary patients should be recorded according to the situation. First-level care is recorded every day, second-level care is recorded for 2~3 days, and third-level care is recorded for 3~5 days. 5 Problems existing in nursing records and countermeasures 5. 1 Question 5. 1. 1 Nursing records cannot reflect the dynamic process of nursing. Nursing record is a part of hospital medical records, but it is a phased nursing record with few summaries. At present, there is no unified national standard for nursing records, and the nursing frequency has not been determined. Most nurses only take notes. With the increasing demand of patients for medical care, nursing and even logistics services, holistic nursing and humanistic nursing have been put forward one after another, which have been respected and developed in hospitals, and the role of nurses has gradually changed from a single one to multiple types. Adhering to the system of daily nursing rounds plays a positive role in properly handling the relationship between nurses and patients, promoting patients' rehabilitation, ensuring the quality of nursing work and reducing the occurrence of medical disputes. A, director of the nursing department at any time every day, check the nurse's labor discipline, aseptic technique operation, critical care, disinfection and isolation, service attitude, etc. , and record the results of the round. 2, specialist nursing rounds once a month, with detailed rounds of results. 3, choose a good difficult cases, critically ill patients or special diseases for rounds. Discuss after rounds, and modify the nursing plan in time. 4, according to the requirements of nursing work every month, item by item, rounds, strict inspection and evaluation, promote the quality of nursing standards. Second, the head nurse rounds 1, and patrols the ward every morning to check the ward order and the implementation of the nurse post responsibility system. 2, every two weeks for a specialist nursing rounds, methods with the requirements of the director of the nursing department rounds. 3. Regularly check the writing of nursing forms and the registration of various forms.
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Model essay on nursing three-level ward round record
Model essay on nursing ward round record
Hello! Let me say something.
A, nursing business rounds:
1, clinical nursing rounds:
It is to conduct nursing rounds on nursing problems, measures, nursing effects and nursing quality of new patients and critically ill patients, with the purpose of checking and guiding the work quality of responsible nurses and revising guiding nursing measures. Time is less than 20 minutes.
2, case nursing rounds:
It is a ward round for patients with difficult, complex, special and newly developed treatment and nursing items, nursing schemes, nursing measures and nursing quality. The purpose is to guide and solve the patient's nursing plan and nursing measures. The time should be 30-40 minutes.
Page 1
3, nursing teaching rounds:
According to the requirements of the teaching syllabus, the nursing scheme of typical cases of specialized diseases was selected for ward rounds. The purpose is to understand the nursing quality of patients, understand the ability of guiding nursing students to use nursing procedures, be responsible for the quality of nursing teaching, and review the relevant knowledge of diseases.
Second, the nursing administrative rounds:
1, hospital nursing administrative rounds:
Hospital-level nursing quality organization checks, understands, guides and coordinates the correction process of nursing management quality in clinical nursing units.
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2, department level nursing administrative rounds;
Branch nursing management organizations check the quality of nursing management in nursing units, and understand, guide and coordinate the process of correcting the quality of nursing management.
3, nursing unit nursing administrative rounds:
The nursing unit organizes a nursing quality group to check the nursing management quality of the nursing unit, find problems, solve problems and eliminate potential safety hazards.
The following is a record of patient rounds for your reference:
Nursing ward round record
Time: March 27th, 2008
Page 3
Number of participants: 10.
Investigator: Wang * *
Patient bed number: 15 bed.
Patient name: Sun * *
Diagnosis: hypertensive cerebral hemorrhage
Main contents:
1, the nurse in charge briefly described the condition.
2. The nurse in charge reports the patient's nursing problems.
3. Nursing points of ventricular drainage.
4. The patient's healthy side, paralyzed side and supine position are correct.
Page 4
5. Turn over for hemiplegic patients (actually operated by two people).
6, paralyzed limb function exercise (responsible for the nurse demonstration).
7. Health education evaluation: Ask the patients' families how to prevent constipation. Physical function exercise (practical exercise).
That's it! I hope I can help you!
Obstetric nursing ward round record
To provide you with records, please refer to:
Medical administrative rounds of obstetrics and gynecology in Ruijin Hospital
Time: June 28, 2007 at 3:00 pm Location: Building 6/Obstetrics and Gynecology Department, floor 0/2, KLOC.
Page 5
Participants: Yuan Kejian, Gong, Party Office, Nursing Department, Director of Obstetrics and Gynecology, Head Nurse, Emergency Department, etc.
Analysis of medical quality in obstetrics and gynecology in 2007
I. Increased workload:
1, the number of outpatients increased (1~ April 2006, 24742; 1~ April 2007, 30942);
The amount of treatment in wards and the number of surgical cases have increased.
2, the number of disputes decreased (in 2006, 1 1; 1~ April 2007, 3 cases);
The average length of stay decreased (8.35 days ↘7.40 days in gynecology; Obstetrics 5.00 days (↘4.96 days)
Page 6
The utilization rate of beds increased (gynecology104.7% ↗105%; Obstetrics107.7%138.5%)
Second, the current problems:
1, medical insurance cost overrun
Reason:
(1) When medical insurance patients and specialized hospitals are transferred, the cost of examination and treatment increases.
(2) The number of laparoscopic operations increased.
(3) The single disease index of medical insurance is low and the operating cost is high.
Countermeasures:
Page 7
(1) Further simplify the examination and use antibiotics rationally.
(2) reduce unnecessary charges
(3) Consider increasing the single disease index of medical insurance as appropriate.
2. There are many departments in obstetrics and gynecology, and the personnel are scattered.
The workload has obviously increased.
(1) The number of senior doctors is greatly reduced.
(2) There are many departments and limited personnel.
(3) arouse the enthusiasm of personnel to ensure the quality of medical care.
4.b-ultrasound room
(1) The successor echelon is in urgent need of training.
Page 8
(2) Ultrasonic instruments are obsolete, so it is difficult to screen obstetric malformations.
(3) The environment of the B-ultrasound room is poor and there is no ventilation equipment.
5. There is no colposcopy and liquid-based cytology (TCT) examination in outpatient department, and many patients are lost, which is prone to medical disputes.
6. Respond to the obstetric baby boom.
(1) The layout of real estate should be adjusted to increase beds.
(2) Department coordination, strengthen the management of medical personnel, and ensure the quality of medical care.
Third, the nursing staff:
Page 9
1, aging, facing retirement
2. Strong professionalism and strong talent training cycle.
3. Obstetrics has 13 nurses, which is difficult to meet the growing demand.
4. Obstetric space is narrow and facilities are outdated.
Four, the need for coordination of various departments:
1. Many pathological reports from the Department of Pathology are sent back incorrectly, which affects the quality and efficiency of clinical work.
2. Blood supply in blood transfusion department is late, and platelets are kept for a long time, so it is often difficult to rescue critically ill patients in obstetric emergency.
Page 10
3. The waiting time of patients undergoing elective surgery is long, which affects the satisfaction rate.
4. There is no charge on the 7th floor of the outpatient clinic on Saturday, and the patient travels back and forth from the 2nd floor to the 7th floor for many times, resulting in great opinions and disputes.
5. After Friday and Saturday 1 1:30, the hospitalized patients did not have ECG and chest X-ray examination. Patients have long waiting time and long hospitalization days.
6. copier problem. I hope to inform you by fax or in writing, because mobile phone messages are sometimes not received, sometimes received late, or even expired.
Verb (abbreviation of verb) feedback and rectification
Page 1 1
1. There is no charge on Saturday at the 7th floor of the outpatient department: the problem has been solved through the coordination of the outpatient department, and it will be implemented from July 7th, 2007 this Saturday.
2. Gynecological emergency clinic should be equipped with stethoscope and sphygmomanometer: the clinic has vertical sphygmomanometer.
3. Suggestion: develop diversified forums to strengthen communication between doctors and patients; For the development of hospitals and disciplines, the treatment and nursing of newborns can not be ignored.
Please continue to pay attention to China Nursing Network! We will serve you wholeheartedly!
Model essay on nursing rounds record —— How to write nursing rounds record for patients with mental perception disorder
Page 12
In general nursing, put the patient in the intensive care unit and check whether there are movable dentures in the patient's mouth. If you have false teeth, you should pull them out.
Patients should try to avoid wearing glasses to prevent falling and injury. Strengthen patrols to detect seizures in time.
Take necessary measures to avoid inducing factors. Inducing factors include excessive drinking, eating, drinking, constipation, poor sleep, emotional excitement, stuffy air, strong sound and light stimulation, and sudden cessation of taking antiepileptic drugs.
Pay attention to the condition. When the patient complains of chest tightness, numbness of limbs, bad smell, mood changes and hallucinations, immediately put the patient on his back and prepare for sudden unconsciousness.
Page 13
Encourage patients to develop good living habits, work and rest regularly, defecate, avoid constipation and overwork, eat lightly, and reduce strong light stimulation. Seriously implement drug treatment requirements and nursing routine.
Observe the drug reaction, give the medicine according to the doctor's advice on time, and ensure that the patient will take the medicine. Pay attention to the side effects after taking the medicine.
Including whether there is ataxia, lethargy and dizziness. Don't stop taking medicine or changing medicine suddenly.
So as not to induce epilepsy. Family support, patients should visit frequently during hospitalization, so that patients can enjoy the warmth of family. Patients' home care should pay attention to urge patients to take medicine, care about the changes of patients' condition, reduce the stimulation to patients and prevent the recurrence of their condition.
Page 14
Symptomatic nursing: grand mal nursing: 1. Let the patient lie on his back and quickly put the dental pad between the upper and lower molars in the mouth to prevent biting his lips and tongue. In case of emergency, horns and towels can be used instead, but be careful not to fill the whole mouth, so as not to affect the collection and arrangement of respiratory medicine education network. 2. Loosen the collar button and belt.
Protect mandible and limbs. 3. Turn the patient's head to one side after the convulsion stops to prevent saliva from being inhaled into the trachea by mistake.
4. Observe the recovery of breathing. If the respiratory recovery is not smooth and the face is cyanotic, artificial respiration should be performed immediately, oxygen should be given, and respiratory stimulants should be used if necessary. 5, check whether there is any fracture and dislocation in patients, patients in bed rest, specialist care.
Page 15
Protect patients from falling. Continue to observe whether the patient has signs of persistent attacks.
Incontinence patients change clothes and pants in time. Nursing care of status epilepticus: If convulsion persists, it often leads to circulatory failure, respiratory disorder and electrolyte disorder, which is life-threatening.
The attack should be stopped immediately. In the process of cooperating with the rescue, the nurse should do: 1, nurse by special person, closely observe the condition, record the frequency of attack in detail, the duration and interval of each attack, and pay attention to the changes of vital signs. 2, keep the respiratory tract unobstructed, prevent hypoxia.
Turn the patient's head to one side to facilitate the discharge of oral secretions, suck sputum at any time, and do artificial respiration in time when breathing difficulties are found. 3. Patients with high fever should be given physical cooling.
Page 16
4. Ensure the implementation of treatment. 5. Protect limbs and do basic nursing.
6. After 24 hours of seizure control, mixed milk can be fed by nose according to the patient's consciousness.
What are the contents of nursing rounds?
Classification of nursing rounds: 1.
According to the nature of rounds, it is divided into clinical professional rounds, teaching guidance rounds and routine evaluation rounds. Clinical ward round is a nursing ward round with rare clinical cases, particularly critical cases, complicated major operations, new businesses and technologies, special examinations, problems often encountered in nursing work and experiences and lessons learned in work as the main contents.
Page 17
There are two kinds of teaching guidance rounds: one is the nursing rounds organized by the teaching teacher according to the syllabus of the school where the nursing students are located; The other is the nursing rounds organized by the head nurse or the nursing department, which are attended by clinical nurses and focus on selecting a disease or problem from the clinical business rounds. Routine evaluation rounds are nursing rounds with the implementation of nursing measures, nursing effects and other nursing procedures as the main contents, in order to improve nursing methods and improve nursing quality.
2。 According to the nursing level, it is divided into nurse group leader rounds, head nurse rounds and nursing department rounds.
In systematic holistic nursing, ward nurses are divided into clinical nurses, head nurses and head nurses. Using nursing procedures to carry out graded nursing rounds can give full play to the technical advantages of nurses with different energy levels and play their respective roles.
Page 18
Clinically, special nursing rounds should belong to clinical professional rounds. The form of ward rounds mostly uses the content of nursing degree to carry out special ward rounds.
The content of rounds is mainly specialized nursing knowledge.
Ordinary care record sheet writing sample
Nursing records are nurses' reflections on patients' vital signs, and are the concrete embodiment of the implementation of various medical measures and their results in the process of medical nursing activities.
(3) Nursing physical examination: such as temperature, pulse, respiration, blood pressure, weight, consciousness, expression, general nutrition, skin and mucosa, physical activity, allergic history, psychological state, etc. (4) Living habits: such as diet, sleep, defecation habits, hobbies, etc.
Page 19
This nursing sheet integrates nursing plan, nursing measures, measures basis and effect evaluation, which is more convenient to record. In the process of writing, it is not necessary to list the nursing diagnosis, measures and results separately, but it is reflected in the nursing course record, as follows: (1) Nursing record is an objective record of the nursing process of patients during hospitalization according to the doctor's advice and illness, so as to avoid repeating the same nursing problems without the effect evaluation of nursing measures. According to the patient's condition, record the patient's conscious symptoms, emotions, psychology, diet, sleep, defecation and defecation, as well as the new symptoms and signs of the patient.
Seriously and truthfully record the treatment measures implemented according to the condition, the effect after the implementation of nursing measures and adverse reactions. (2) Record the positive results of laboratory examination so as to observe the condition, but don't record the contents of subjective analysis.
Page 20
(4) Pay attention to vital signs. If the doctor fails to give treatment advice when the patient has symptoms and asks for "observation", "observation" is also a doctor's order. The nurse should record the doctor's full name and the contents of the doctor's orders.
(5) On the day of discharge or before discharge 1 day, the patient's condition, prognosis and health problems that need to be explained to patients and their families should be clearly stated. (6) Before the operation 1 day, the patient's preoperative preparation should be recorded, and whether the condition has changed; Records should be made in time on the day of operation, and at least 1 time should be recorded in each shift in the first three days after operation, and the changes of the condition should be recorded at any time.
On the day of discharge, record the postoperative wound of the surgical patient, whether there is a drainage tube, whether there is a suture removal, and the contents of health education and guidance that need to be explained to the patient and his family. 3 Discharge instruction The discharge instruction was written before the patient was discharged 1 day in duplicate (one copy was taken away by the patient). According to patients' different diseases, psychology, treatment and nursing conditions and living habits, the guidance contents include diet, rest, medication, reexamination, preventive health care knowledge and related matters needing attention.
Page 2 1
Try to be specific, don't just write principled words, it should vary from person to person, and it can't be stereotyped. 4 Matters needing attention in writing nursing records (1) Writing format: write the year, month and day at the beginning of the first nursing course record, and start writing the first day of the patient's admission in another blank space, describing the general situation of the patient, including the psychological state and the degree of 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.
Record another line and sign your full name on the right. (2) In the process of nursing, it is necessary to avoid repeatedly recording the same nursing problems without evaluating the effect of nursing measures.
Page 22
It is necessary to embody more nursing methods, not just to follow the doctor's advice. (3) The changes in patients' mind and body should be reflected in the process of nursing records, and the contents of health education should be recorded appropriately.
In addition, it is necessary to accurately record nursing rounds, nursing case discussions and patient care contents. (4) Nursing records should be consistent, that is, the effect evaluation of some previous nursing problems may be short-term or long-term, and the reasons should be explained according to the situation.
(5) The related contents of nursing records should be consistent with the medical records, and there should be no discrepancy, so as not to cause legal disputes. (6) When writing nursing medical records, the head nurse should make an overall arrangement, reasonably divide the work, select experienced senior nurses to write, and the head nurse should give guidance to ensure the quality of medical records.
Page 23
(7) The nursing process of critically ill and rescued patients should be recorded at any time, and ordinary patients should be recorded according to the situation. First-level care is recorded every day, second-level care is recorded for 2~3 days, and third-level care is recorded for 3~5 days.
5 Problems existing in nursing records and countermeasures 5. 1 Question 5. 1. 1 Nursing records cannot reflect the dynamic process of nursing. Nursing record is a part of hospital medical records, but it is a phased nursing record with few summaries. At present, there is no unified national standard for nursing records, and the nursing frequency has not been determined. Most nurses only take notes.
Contents of nurses' morning rounds
With the increasing demand of patients for medical care, nursing and even logistics services, holistic nursing and humanistic nursing have been put forward one after another and respected and developed in various hospitals, and the role of nurses has gradually changed from a single one in the past to multiple types. Adhering to the daily nursing rounds system plays a positive role in properly handling the relationship between nurses and patients, promoting patients' rehabilitation, ensuring the quality of nursing work and reducing the occurrence of medical disputes.
Page 24
First, the director of nursing rounds
1, the director of nursing department makes rounds at any time every day to check the nurses' labor discipline, aseptic technique operation, critical care, disinfection and isolation, service attitude, etc. , and record the results of the round.
2, specialist nursing rounds once a month, with detailed rounds of results.
3, choose a good difficult cases, critically ill patients or special diseases for rounds. Discuss after rounds, and modify the nursing plan in time.
4, according to the requirements of nursing work every month, item by item, rounds, strict inspection and evaluation, promote the quality of nursing standards.