Nurses need to take care of patients all the time and are patient-centered. The work content is relatively complicated. The new year has just arrived. Let's make a work summary for the old year. The following is the "2020 Internal Medicine Head Nurse Year-End Work Summary" compiled by me for everyone. It is for reference only. You are welcome to read it. 2020 Internal Medicine Head Nurse Year-end Work Summary (1)
Under the leadership of the Nursing Department and in accordance with the Nursing Department’s work plan goals, the Internal Medicine Department successfully completed various work tasks throughout the year. The summary is as follows:
1. Strengthen nursing safety management
Supervise the implementation of various core systems in a planned manner, discover problems in a timely manner, and analyze and rectify them.
(1) Implementation of the verification system: The inspection found that the double verification of temporary medical orders after dispensing medicines was not in place, the active verification of infusions was not in place, and the labeling was not standardized, etc. Continuous improvements were made to the problems that emerged during the inspection, and the inspection process in each link was standardized. The inspection defects were significantly reduced compared with before.
(2) Implementation of the handover system
1. The lintel column of the handover report was incomplete, the admission situation was not described or the description was not specific, and various ratings were not carried out. Nursing care The measures are not comprehensive, and there is no continuous condition observation in the next shift. Through continuous improvement measures such as training, evaluation, and continuous inspection and feedback, shift handover reports are more standardized than before.
2. The bedside handover is unclear about the handover subject. The main task is to check the head nurse. The responsible nurse cannot take the initiative to pick up the patient in charge, does not take the initiative to introduce himself and understand the condition, and does not take the skin handover of bedridden patients seriously. The night shift nurse Problems such as handover of bed units for critically ill patients cannot be sorted out. Through training and handover standards, follow-up inspections and guidance, bedside handovers are more standardized than before.
Implementation of the three-level nursing system
(1) In the implementation of hierarchical care, inspections are not carried out according to the level of care, especially for chemotherapy patients, and the fluid input and local skin are not carefully checked during the handover. situation, it is impossible to patrol and record every hour, especially at noon and afternoon. The content of disease observation is unclear. When executing oral medication instructions, the nurse cannot grasp the patient's medication status. The patient cannot grasp the drug's effects, side effects, and medication methods. Nursing instructions such as measuring abdominal circumference for patients with ascites and oral care for fasting patients are not in place. In order to solve the problems of poor health education effect and other issues, by clarifying the responsibilities of responsible nurses and responsible team leaders, and following the inspection and guidance, the implementation of the hierarchical nursing system is more standardized than before. (2) Improve the emergency plan, strengthen emergency plan drills and positioning rescue drills, and improve the emergency preparedness of nurses. processing power. The Department of General Internal Medicine organized an emergency drill for hypoglycemia and falls and an emergency drill for anaphylactic shock. Each ward organized drills with corresponding content based on the characteristics of the ward. Three wards successfully rescued 2 patients with anaphylactic shock and one patient with anaphylactic shock. When a patient committed suicide in the district, the nurses were able to rescue and report the incident in an orderly manner according to the plan. The nurses in each ward were able to conduct rescue operations in an orderly manner according to the localized rescue plan, which improved the success rate of rescue and was recognized by the doctor.
(3) Organize safety meetings regularly, conduct timely analysis of defects discovered during inspections, and make serious rectifications.
2. Continuous improvement of nursing quality
All nursing quality assessments meet the standards.
(1) Quality of writing nursing documents: We have trained on the format requirements for writing nursing documents, formulated the key points for observing common diseases in various departments, trained on various scoring methods and applications, and formulated nursing records for common diseases. Writing template, the writing quality of young nurses has improved than before.
(2) Management of rescue items and drugs: The rescue vehicle was changed to seal management, and the methods of seal affixing, handover and inspection were standardized.
(3) Management of the head nurse: The young head nurse was trained in writing various record books, standardized the work process of the head nurse, followed up with inspection and guidance, and improved the management ability of the head nurse.
(4) Strengthen the assessment, early warning, and follow-up examination of patients at high risk of pressure ulcers, and pay attention to the dynamic observation of pressure ulcer scores when their condition changes. Except for unavoidable pressure ulcers, the incidence of pressure ulcers in the hospital is 0.
(5) Basic nursing quality: Through standardized admission assessment and shift handover assessment, basic nursing problems can be discovered in a timely manner. For example, whether the nails are trimmed, whether the bed unit is clean, whether the lying position is appropriate, whether the infusion is standardized, etc. Each group of nurses has a treatment and care sheet. The responsible team leader and head nurse promptly formulate nursing instructions for problems discovered by the responsible team leader and head nurse, and instruct the nurses to write them on the treatment and care sheet and implement them in a planned manner. They check and supervise in a timely manner, and the quality of basic nursing care is improved than before.
(6) Quality of critical illness care: Each case of critical illness was inspected and guided, focusing on cultivating nurses’ ability to evaluate and observe conditions, find nursing problems, correctly implement nursing measures and communicate with patients. and the ability to communicate with family members, etc. List the key points for observing the condition of critically ill patients and the key points for nursing care during the period, explain to nurses what changes in the condition need to be reported to the doctor, and conduct predictive training on possible situations, making it easier for young nurses to implement them and improve the level of critical care care.
(7) Quality of Traditional Chinese Medicine Nursing: According to the types of Traditional Chinese Medicine nursing plans formulated by the Nursing Department in each ward, training was conducted and the implementation was organized. All specified plan diseases must have Traditional Chinese Medicine nursing measures and Traditional Chinese Medicine treatment techniques. Nurses can master the methods of TCM syndrome differentiation, and the utilization rate of TCM nursing technology is higher than before.
3. Effectively implement overall nursing care under the responsibility system and improve the quality of nursing services
Each ward is equipped with relatively reasonable human resources. Each ward is divided into two major responsibility groups, each group Divided into several groups, each responsible nurse is responsible for a certain number of patients according to their ability level. The responsibilities of the responsible team leader and responsible nurse are clarified, and the nurses are guided to reasonably plan their working hours, carry out various treatments and care in a planned manner, and actively inspect patients. The number of bell ringings has been reduced, proactive communication with patients has been achieved, and the relationship with patients has been strengthened. The nurse-patient relationship is now more harmonious than before. Strengthen the routine study of specialist diseases, nurses' ability to observe conditions, find problems and deal with problems are improved than before. Training and on-site guidance on basic nursing operations and specialist nursing operations are strengthened, and operations are standardized than before.
4. Strengthen training and assessment, and improve nursing ability level
***Organize hospital-wide nursing rounds x times, general nursing rounds x times, and specialist nursing training x times . Lectured x times of business learning and training for nurses at all levels, assessed more than x number of nurse operations, assessed more than x number of young nurses’ clinical abilities, guided nurses to participate in the Yancheng City First Aid Technology Operation Competition, and won the third prize in the group.
5. Shortcomings
1. The academic atmosphere is not enough and there is no thesis.
2. Junior nurses have insufficient communication skills and patient satisfaction needs to be improved. 2020 Year-end Work Summary of the Internal Medicine Head Nurse (2)
In accordance with the overall requirements and deployment of the hospital nursing department, we will conscientiously do a good job in the departmental work, and better realize the hospital plan by strengthening the management of the nursing work in the undergraduate department. and goals. With the care and support of the hospital leaders and the Nursing Department, and with the joint efforts of the general nurses, the department's nursing work has successfully completed various tasks assigned by the hospital. The nursing work in 20xx is now summarized as follows:
1. The department personnel have a clear division of labor and strengthen the management of the nursing responsibility system
In accordance with the requirements of the Nursing Department, the department has established and completed various Rules and regulations. The nursing staff in the department have a clear division of labor according to workload and implement responsible nursing care. At work, we strengthen the management of the nursing staff's responsibility system so that each nursing staff can clarify their job responsibilities and do a good job in nursing work seriously and meticulously.
2. Patient-centered, promote humanized services, and strengthen nurse-patient communication
In order to adapt to the needs of medical services, create a high-level service concept and humanistic care, and establish a good The social image promotes the sustained and stable development of the hospital. The department adheres to the patient-centered approach and provides warm and thoughtful humanized services to patients on the basis of respecting, understanding, and caring for patients. It respects the patient's personal dignity and values ??the patient's personality and psychology. needs to meet the physical and psychological needs of patients to the maximum extent.
First of all, the bed nurse warmly receives the newly admitted patient, sends the patient to the bedside, and actively introduces the ward environment, work and rest time, rules and regulations, and attending physician to the patient or family members. During the patient's hospitalization, the nurse in charge of the bed will incorporate psychological care and disease knowledge education into the focus of nursing work. Understand and pay attention to the patient's psychology, living conditions and needs, and incorporate family-friendly services into the work. Department nurses care about patients in their daily lives and help patients with difficulties solve their problems.
Strengthen psychological care, comfort patients with loving family affection, enhance patients’ confidence in overcoming the disease, and promote early recovery. In nursing work, we pay attention to communication and communication with patients, and win the understanding and trust of patients with a non-discriminatory, respectful and caring attitude.
3. Strengthen ward management and create a good medical environment for patients
In order to ensure that the items in the ward are neat, tidy and orderly, the head nurse leads the nurses to conduct daily inspections for the patients. Wet sweep the bed, tidy up the bed unit and place items. Strengthen the management of ward cleaners and do a good job in hygiene and cleaning for patients, so that the ward environment is clean, elegant and comfortable for patients.
4. Strengthen disinfection and isolation, and strictly control the occurrence and development of nosocomial infections
Strictly implement the disinfection and isolation system formulated by the nosocomial infection management leading group, and conscientiously implement the principles of aseptic technology in nursing operations . When treating patients, one person has one needle and one tube, and the bed is wet-swept every day. Wipe the bedside table and bed with disinfectant towels every day, disinfect and wipe the treatment room table every day, and perform ultraviolet radiation disinfection. Air disinfection and air culture are carried out regularly every month. All kinds of medical waste are carefully destroyed, soaked, packaged, handed over to relevant personnel, and registered in a timely and conscientious manner. After the patient is discharged from the hospital, the bed unit undergoes terminal disinfection to prevent the occurrence of nosocomial infection.
5. Strengthen the writing of nursing documents and regular inspections and assessments of various nursing tasks to improve the quality of care
Quality management is an eternal theme in hospitals. Regular inspections and assessments are an important step in improving the quality of care. Guarantee of quality of care. In order to improve the quality of nursing, based on the characteristics of the department's nursing work, combined with the inspection and assessment rules formulated by the Nursing Department, the department formulates the key points of nursing assessment every month, conducts inspections and assessments from nursing forms, document writing and basic nursing, and carefully completes them. Record. In terms of basic nursing quality management, we will strengthen basic nursing work for critically ill patients. At work, strictly implement nursing operation specifications, emphasize and implement aseptic operations, and take personal protection seriously. In terms of link quality, attention is paid to the timeliness and standardization of nursing medical record writing. Medical record writing requirements are standardized, and at the same time, nursing staff are required to continuously enrich and enrich the writing content on the basis of timeliness, truthfulness and accuracy, and improve the connotation and quality of nursing cases.
6. Pay attention to improving the professional quality of nurses and strengthen the three basics and three strict training
In order to better serve patients and reduce their pain, nursing staff must have good professional skills and Solid expertise. For this reason, the department pays attention to the training of professional quality of nursing staff. Under the strict requirements and organization of the hospital's nursing department, we actively participate in business training and lectures throughout the hospital. The department regularly organizes nursing staff to learn and train professional knowledge and operational skills every week.
In the past year (x months), our department has a total income of xxx yuan, *** admitted xx new patients, xx first-level care, xx critically ill patients, rescued patients xx times, and successfully rescued xx deaths xx Person, xx times of intravenous infusion, xx times of intravenous blood transfusion, xx times of intravenous injection, xx times of intramuscular injection, xx times of Chinese medicine enema, xx times of Chinese medicine wet compress, xx times of acupoint massage, xx times of massage, xx times of acupuncture, and xx times of cupping.
While affirming the achievements, we should also be clearly aware of the existing shortcomings, and we must boldly innovate and persevere in management awareness; in terms of standardized services, we still need to improve; in terms of the implementation of rules and regulations , there are still a few comrades with indifferent consciousness. Therefore, in 20xx, we will continue to improve and strengthen the construction of the department's nursing team. Everyone starts from the essential work, constantly enriches and improves themselves, and becomes a high-quality and excellent nursing staff.
We believe that with the efforts of the hospital leaders, the nursing department and all the nursing staff in the department, we will be able to do better nursing work! 2020 Internal Medicine Head Nurse Year-end Work Summary (3)
In this year, internal medicine nursing followed the "patient-centered" approach advocated by the Hospital Management Year activities to improve the quality of medical nursing services, consolidate basic nursing, and establish a safe hospital "The service purpose of this year is to conscientiously implement this year's nursing plan, improve various nursing rules and regulations, improve service processes, improve the hospitalization environment, strengthen nursing quality control, and continue to improve nursing quality in accordance with the basic requirements and standards of hospital nursing service quality evaluation standards. The nursing work in 20xx is now summarized as follows:
1. Implement the nursing talent training plan and improve the professional quality of nursing staff
Conduct three-based training for nursing staff at all levels and organize general nurses Learn various nursing risk emergency plans and core nursing systems, and conduct questions on various basic theoretical knowledge, hospital experience knowledge and specialist knowledge during morning nursing rounds and morning meetings, and conduct monthly theoretical and technical operation assessments. All nursing staff actively participate in various business and skill operation training organized by the hospital. Each nurse can master cardiopulmonary resuscitation first aid technology and various rescue operation skills and procedures. Among them, the overall average score of the nursing theory knowledge assessment is above 90 points; the skill operation assessment: the average score of oral care is xx points, the average score of sputum suction nursing is xx points, and the average score of cardiopulmonary resuscitation is xx points.
2. Improve service processes and improve service quality
Standardize the service process for receiving newly admitted patients, implement standardized terminology in the service process, and bring various conveniences to patients’ lives. Extensively listen to the opinions of patients and caregivers on nursing services, find out the causes of existing problems, propose corrective measures, and continuously improve service quality. Throughout the year, there were no complaints or nursing disputes from patients and their families, and the patient satisfaction rate reached xx or above.
3. Improve various nursing regulations and operating procedures to prevent nursing errors and accidents
Nurses will conduct safety awareness education every week to find potential safety hazards at work and improve rectification Measures are taken to eliminate the hidden dangers of errors and accidents, conscientiously implement various nursing regulations and operating procedures, give full play to the role of the quality control team within the department, and regularly and irregularly inspect the implementation of various nursing systems, so that the incidence of nursing errors and accidents is zero.
IV. Strengthen and improve the quality requirements for writing nursing documents
Strive to be accurate, objective and continuous. Nursing documents are also legal documents and an objective basis for determining medical disputes. In the writing process Every nurse can carefully write based on the patient's condition that he or she observes, and can reflect the changes in the patient's condition objectively, truly, accurately, timely, and completely, and constantly strengthen the important benefits of formal writing of nursing documents, so that every nurse can correctly write nursing documents. Writing attitude, and at the same time strengthening supervision and inspection, each shift will check whether there are any errors in the records of the previous shift, the quality control team will conduct regular inspections, the head nurse will conduct regular and irregular inspections and the final quality inspection of discharge medical records, correct any problems found in a timely manner, and provide monthly care Analyze the quality of documents, propose rectification measures for existing problems, and continue to monitor. For x discharge medical records from June to June this year, the writing quality of nursing documents reached x points or above.
5. Standardize ward management
Establish a people-oriented hospitalization environment so that patients can reach a physical and mental state that understands treatment. The ward is regularly ventilated every day, and the ward is kept quiet, clean, and the air is fresh. Provide safe and effective protective measures to patients with disorders of consciousness, care for patients according to graded care standards, implement health education, strengthen basic care and case care for critically ill patients, and meet the reasonable needs of patients and their families. In 20xx (x month), there were x number of inpatients, an increase of Symptoms, the incidence of bedsores is 0.
6. The intactness rate of first-aid items reaches 100
First-aid items are managed under "four fixed conditions". A dedicated staff conducts a comprehensive inspection once a week, and the head nurse conducts weekly inspections from time to time. Spot checks ensure that first aid items are always in emergency condition.
7. There are still many deficiencies in the work
1. Basic nursing care is not implemented in place, and newly admitted patients in individual shifts are not treated in time, and the lying position is uncomfortable. Ward management needs to be improved, and patients bring more supplies.
2. Some nurses do not have a strong concept of sterility and do not dispose of disposable sterile items in a timely manner after use. The learning atmosphere is not strong enough and there are no academic papers; nursing documents have defects such as missing items, omissions, and lack of continuity of information; health education is not deep enough and lacks dynamic continuity.
8. Outlook for next year
On the basis of maintaining the original achievements, we will continue to work hard: continue to strengthen business skills learning and training, improve nursing skills; further improve the nursing service process and quality control plans and conscientiously implement them; strengthen the implementation of basic nursing care, strengthen ward safety management, and create high-quality nursing services. 2020 Year-end Work Summary of the Head Nurse of the Internal Medicine Department (4)
In 2020, under the leadership of the Nursing Department of the hospital, the Department of Internal Medicine has been well completed in line with the service tenet of “everything is patient-centered and everything is for the patient”. Various nursing tasks have achieved good results. The work situation is summarized as follows:
1. Conscientiously implement various rules and regulations
Strict implementation of rules and regulations is the fundamental guarantee to improve the quality of nursing and ensure safe medical care.
1. According to the requirements of the Nursing Department, the responsibilities of nursing staff at all levels were reiterated, detailed assessment rules for personnel at all levels were formulated, the responsibility systems for various positions and nursing work systems were clarified, and the assessment of nursing staff at different levels in each department was completed. and recognition.
2. Earnestly implement the checking system:
(1) Require medical orders to be checked in three shifts and four, and have records;
(2) Various nursing items The operation strictly requires three checks and seven pairs;
(3) Improve the implementation of the patient identity verification process, revise the blood transfusion check system, diet check system and continuous improvement process.
(4) Develop critical value processing procedures and systems in accordance with the requirements of the Nursing Department and relevant regulations.
3. Conscientiously implement the relevant regulations and plans of the Nursing Department, carefully read the grade hospital evaluation rules, prepare various data registration books according to specifications, write various nursing document templates, and scientifically fill in various information data.
4. Refine the shift handover system and conduct regular inspections, strengthen morning and evening care, and use scientific methods to count and prevent complications.
2. Improve the management level of the head nurse
1. Cooperate with the Nursing Department to unify the specifications of the head nurse’s ledger records: require the head nurse to submit some ledgers to the Nursing Department before the 5th of each month, and Supervise and implement the annual plan, quarterly arrangement, and monthly plan set by the head nurse that are suitable for the department. The head nurse will report monthly work statistics according to the requirements of high-quality nursing, so as to summarize experience and carry out work.
2. Adhere to the head nurse regular meeting system: according to the requirements of the hospital, a regular meeting of the internal medicine head nurse is held once a month. The content is: business learning, nursing rounds, arranging the focus of this month’s work, and summarizing the work of the previous month. The existing advantages and disadvantages, and put forward corresponding rectification measures, provide feedback to each head nurse on some quality control inspections in the nursing department, and learn relevant information about head nurse management.
3. Visit the ward every month to check the quality of nursing care and provide timely feedback to continuously improve the management level of the head nurse.
4. Cooperate with the Nursing Department to organize head nurses to go out for study and visits, and assist the Nursing Department in organizing head nurses to conduct management knowledge training, learn advanced experience, and expand their knowledge.
3. Strengthen the construction of medical ethics and medical style among nursing staff
1. Cooperate with the Nursing Department to continue to implement the nurses’ behavioral norms and implement nurses’ civilized language in daily work.
2. Continue to carry out health education, arrange for plainclothes personnel to enter the ward to issue satisfaction survey forms to inpatients, be as realistic as possible, ensure that the results are true and reliable, and propose rectifications for problems existing in the satisfaction survey Measures to improve the results according to PDCA method.
3. Regularly hold symposiums on work breaks in the Department of Internal Medicine to solicit opinions from patients and their families, and provide patients with suggestions and requirements to maximize improvement and satisfaction.
4. Cooperate with the Nursing Department to provide standardized and comprehensive training and training for newly assigned nurses on pre-job professional ethics education, rules and regulations, nurse behavioral standards education and basic nursing knowledge, specialist knowledge, and nursing technical operations. After assessment, those who pass the examination will be allowed to take up the post.
IV. Improve the professional quality of nursing staff
1. Cooperate with the nursing department to conduct three-level training for in-service personnel and organize theoretical examinations.
2. Participate in morning meetings of various departments from time to time to check and assess the comprehensive abilities of young nurses.
3. On "May 12th Nurses' Day", the Nursing Department held a nursing technology operation competition (intravenous infusion), and the first, second and third prizes were selected and rewarded respectively.
4. According to the plan of the Nursing Department, the nurses in the hospital were grouped into nursing technical operation assessments within x years: intravenous infusion, oxygen inhalation, CPR, aseptic operation, oral care, various injection methods, blood sugar testing, Oral administration, vital signs measurement, nasogastric feeding, perineal care, catheter care, etc.
5. Strengthen the care of critically ill patients and refine the bedside handover system and morning care.
6. Adhere to nursing business rounds: Carry out nursing business rounds in the large internal medicine ward every two months, and discuss nursing diagnosis and nursing measures to achieve the purpose of improving professional quality.
5. The nursing staff completed the nursing work well
1. According to the purpose of the nursing department to adhere to the patient-centered, quality-centered and provide high-quality services to patients, in-depth development Provide patient-centered health education and cooperate with the nursing department to re-formulate health education manuals to familiarize patients with disease prevention, rehabilitation and related medical, nursing and self-care knowledge.
2. Each ward carries out specialist health education lectures and patient meetings to strengthen specialist care and reflect the level and value of nurses’ specialist knowledge.
3. Each department helps each other to overcome the difficulty of staff shortage.
4. This year, internal medicine nursing staff wrote more than 10 nursing papers, one of which was published in SCI journals.
6. Existing problems
1. Some new nurses are not of high quality, their theory and operation are not up to standard, and their comprehensive ability is weak.
2. The xx electronic system is still in the exploratory stage, and nursing writing is not standardized.
3. Basic nursing care in some departments is not in place.
4. Ward management is still unsatisfactory.
In the past year, due to the attention, support and help of the Nursing Department, the nursing work has strengthened internal management and external image, and has achieved certain results in the construction of nursing quality and professional ethics, but there are also certain shortcomings that need to be further improved. improve.