Writing Standard for Nursing Medical Records (ZT) [August 5, 2006 1 3: 59: 00 | Author: Manjiang] Directory1. General rules for writing nursing medical records 2. 1 thermometer 2.2 long-term doctor's advice 2.3 temporary doctor's advice 2.4 evaluation table of hospitalized patients 2.5 nursing record of first visit 2.6. 1 nursing record of ordinary patients 2.6.2 nursing record of critically ill (special observation) patients 2.7 nursing record (sending operation record) 2.8 surgical nursing record 2 .. 10 Patient health. The contents of kloc-0/ 1 inpatient medical record ranking 1 and general rules for nursing medical record writing 1 are objective, true, accurate, timely and complete. 1.2 Unless otherwise specified, all medical records should be written in blue-black pen, and the curves in the thermometer should be marked and connected with pens of corresponding colors. 1.3 Use Chinese and medical terms. Commonly used foreign abbreviations or names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages. 1.4 neat handwriting, clear handwriting, accurate expression, fluent sentences and correct punctuation. If there are typos in the writing process, double lines with the same color should be applied to the typos, and scraping, gluing and painting should not be used to cover up the original handwriting. No more than two marks and no more than three words per record. 1.5 written according to the prescribed format and content, and signed by the corresponding nursing technicians. Nursing medical records written by nursing staff during their internship or probation (one year after graduation, without obtaining a nurse qualification certificate) shall be reviewed and signed by nursing technicians who have obtained legal qualifications and registered in this medical institution. Nursing nurses should write nursing medical records according to their actual qualifications for professional work and after being approved by advanced medical institutions. 1.6 When the superior nurses review, revise and supplement the nursing records written by the lower nurses, they should use a red pen, and the reviser should sign beside the original signature and indicate the date, so as to keep the original records clear and distinguishable. 1.7 adopts the legal unit of measurement in People's Republic of China (PRC): meters, centimeters, millimeters, millimeters, micrometers, liters, milliliters, kilograms, grams, milligrams, micrograms, millimeters of mercury, millimeters of mercury. 1.8 If the nursing medical records are not written in time for rescuing critically ill patients, the nurse should make up the records according to the facts within 6 hours after the rescue and make records. 1.9 Use standardized Chinese characters, simplified characters and variant characters according to Xinhua Dictionary (1992) to eliminate typos. The figures in the report can be Chinese characters, and the figures with more than two digits can be Arabic numerals. 1. 10 The writing time is 24 hours. 2. Writing standard 2. 1. Thermometer 2. 1. 1 column: fill in the name, gender, age, admission date, subject, bed number and hospital number with a blue-black pen. A. Date of admission: The year must be written in 4 digits. B bed number and department: fill in the bed number and department arranged at the time of admission, add "→" after the original bed number and department, and indicate the transferred bed number and department. For example: two internal departments → one external department, 2→3. 2. 1.2 Date column: Fill in in blue ink. Fill in the year, month and day on the first day of each page, separated by short horizontal lines (such as February 9, 2000), and only fill in the day for the remaining 6 days, not the year and month; If a new month or year begins within 6 days, the month, date or year, month and date should be filled in. Write a four-digit year. 2. 1.3 column of hospitalization date: fill in this column with blue and black pen when taking the temperature for the first time that day, and write "1" from the date of admission to the date of discharge. 2.65438+ 0.4 days after operation (or postpartum): when the body temperature is taken for the first time on the same day, fill it in with a red pen, and write "0" on the day of operation and "1" on the day of operation, and fill it in order (the postpartum days are the same). If it is the second operation, stop writing the date of the first operation and rewrite it as "II-0". Take the time of returning to the ward after operation as the date of "0", and fill in it in turn, such as 2000- 12- 18, 16: 40, the 9th day after the first operation. If you return to the ward at 0:30 am on June-12- 19, 2000, write "II-0" in the column of days after operation on February-0/9. The number of days of operation (delivery) shall be filled in continuously until the 10 day of operation. 2. 1.542 ~ 40℃ column: in the corresponding time column, fill in the column of admission/operation/delivery/transfer/discharge/death vertically, then write down the time with a short vertical line (column), and press 12 hours for recording. The specific time and minutes should be the same as the doctor's. Operation does not write time. Professional changes shall be filled in by the receiving department. For example, at 5: 30 in the afternoon, change from Inner One to Inner Two, and when it is accepted by Inner Two, fill in "Change to -5: 30". B. If the emergency department sends the patients with "green channel" directly to the operating room, the receiving department after operation shall fill in "Emergency Admission Operation" and the time according to the admission time recorded by the operation nursing. C. Nurses who leave the hospital without authorization and refuse to monitor their body temperature can indicate "going out" and "refusing to detect" in the 42℃ temperature list, and fill in the number according to the routine temperature monitoring. Those who leave the hospital without authorization should write a good nursing record for each shift. 2. 1.634 ~ 36℃ column: fill in the important diagnosis and treatment measures and special drugs at 34℃ with a blue signature pen, and indicate "Stop xxx" when stopping using, such as "ice blanket", "digoxin" and "artificial assisted breathing" for the date of use; Fill in "Stop Ice Blanket", "Stop Digoxin" and "Stop Artificial Respiration" on the stop date. Fill in the refrigeration mode with a blue signature pen at 35℃. 2. 1.7 Drawing of body temperature curve: a. Symbols with blue strokes: oral temperature ●, underarm temperature ×, anal temperature о. Connect two adjacent body temperatures with a blue straight line, and the thick line does not need to be connected. If the thermometer indicates "ice blanket" or goes out without drawing the body temperature, the body temperatures of two adjacent bodies will not be connected. B the body temperature measured after physical cooling for half an hour is drawn in the same column of the body temperature before cooling, which is indicated by a red circle and connected with the temperature before cooling by a red dotted line. The next temperature should be related to the temperature before cooling. For example, the body temperature is measured at 39℃, and then measured at 39.5℃ after half an hour of treatment, which is indicated by a red circle, and the red dotted line connects 39℃. If the body temperature is re-measured at 38.5℃ after half an hour of treatment, it is indicated by a red circle, and the red dotted line connects 39℃. Fill in the cooling method below 35℃ vertically, such as (alcohol bath, warm water bath, ice compress). If two or more physical methods are used to cool down, write "physical cooling". C. If the patient continues to have high fever after taking cooling measures for many times, the temperature change must be recorded in the nursing record due to the limitation of the temperature sheet record. D. If the temperature and pulse overlap, draw a red circle outside the blue fork; When anal temperature and pulse overlap, draw a red dot in the blue circle to indicate it; When the mouth temperature coincides with the pulse, draw a red circle outside the blue dot. E. If the body temperature does not rise, there is no need to draw the body temperature, and write "Body temperature does not rise" below 35℃ (except those that need to be tested by a thermometer), and there is no need to connect two adjacent body temperatures. F if the patient's temperature suddenly rises or falls, a second interview should be conducted. If the second interview meets the requirements, it should be verified by the English small letter "V" above the original body temperature. You must make up the exam after you leave the ward temporarily. 2. 1.8 Drawing of pulse curve: a. Pulse is indicated by red dots, adjacent pulses are connected by red lines, heart rates are indicated by red circles, and adjacent heart rates are also connected by red lines. B. Patients with short pulse must measure heart rate at the same time and draw it on the temperature list. The red circle indicates the heart rate and the red dot indicates the pulse, and the two are connected end to end. C. If the pulse and heart rate exceed 180 beats/min, draw them all at 180 beats, and draw an upward arrow with a red pen in the same cell on the right side of the pulse. 2. 1.9 Breathing is indicated by numbers, and routine examination is not carried out, but it is tested and recorded according to the illness or doctor's advice. Use a blue-black pen to fill in the corresponding time in the column of breathing. Two adjacent breaths are staggered up and down, first up and then down. 2. 1. 10 column of total liquid intake: fill in with a blue-black pen. According to the nursing routine and doctor's advice, the total intake (including infusion, drinking water, food, etc. ) Statistics are made every 24 hours (from 7: 00 a.m. to 7: 00 a.m. the next day), and numbers (not written units) are filled in the column of the previous day during the night shift. 2. 1. 1 1 discharge column: fill in with a blue-black pen, and only fill in numbers. A. Fecal frequency: fill it in every 24 hours, and record the stool frequency from yesterday noon 12 to today noon 12. If there is no stool, it is indicated by "0"; If it is the number of stools after enema, it is expressed as "1/e" and "0/e" (the number of stools recorded by molecules); If the patient who has defecated still needs enema due to the need of operation, it is indicated by "13/2E" (that is, the patient has defecated once before enema and defecated three times after the second enema), fecal incontinence or false anus is indicated by "*" (fecal incontinence is the case where the number of defecations cannot be controlled), and it is indicated by */E after cleaning enema. For example: 2/500(g). B. Urine volume: according to the doctor's advice, the urine volume shall be counted every 24 hours (from 7: 00 a.m. to 7: 00 a.m. the next day), and the number shall be filled in the column of urine volume the day before night shift. Urine volume of patients with urethral catheterization is recorded in ml/c, and urinary incontinence is indicated by "*". C. Blank column of discharge quantity: the total quantity shall be counted every 24 hours (from 7: 00 a.m. to 7: 00 a.m. the next day), and the figures shall be filled in the column of the previous day after the night shift. According to the doctor's advice, record all kinds of drainage. One drainage tube records one column, and the drainage words are uniform, such as "abdominal drainage", "gastric tube drainage", "thoracic drainage (left)/(right)", "bladder drainage" and "T tube drainage". If both columns are filled in, fill them under the column of drug sensitivity test. According to doctor's advice, 24-hour sputum volume, extract, etc. Can be recorded in the blank column. D. If the total amount is counted for 24 hours according to the doctor's advice, in addition to filling in the total amount on the thermometer, the amount and amount must also be recorded on the nursing record sheet of special observation patients. 2. 1. 12 blood pressure column: fill in with a blue-black pen, and the blood pressure unit is mmHg. A. Measure and record according to the doctor's advice, at least once a week, and measure the blood pressure of newly admitted patients on the same day. B. If blood pressure is measured once a day according to the doctor's advice, fill in the column in the morning, if blood pressure is measured twice a day, fill in the column in the morning and afternoon. C. If the blood pressure is measured more than 3 times a day according to the doctor's advice, in addition to the critical (special observation) nursing records, the blood pressure at 8 am and 4 pm should also be filled in the corresponding columns. 2. 1. 13 weight column: fill in with a blue-black pen. The patient should be weighed when he is admitted to the hospital. If it cannot be measured, it should be marked as "flat car" or "wheelchair". During hospitalization, patients should be measured once a week. If it is temporarily impossible to measure, it should be marked as "bedridden", and the number of measurements can be increased if the condition requires. 2. 1. 14 Drug sensitivity test column: a. Fill in the drug name with a blue-black pen according to the doctor's advice, with the abbreviation "PG" as penicillin, "SM" as streptomycin, "TAT" as tetanus antitoxin and "I" as iodine allergy test. Irregular abbreviations such as procaine and cytochrome C should be filled in with words. For example: PG skin test (-), procaine skin test (-). B drug sensitivity test results: blue-black pen writes brackets, and negative results write "-"in brackets; For the positive result, write "+"in brackets with a red pen. On the back of the thermometer on the first page, write with a red pen that a certain drug sensitivity test is positive at a certain time in a certain month of a certain year, and indicate two exclamation points, for example, "200 1 April 7, 2008 10AM penicillin drug sensitivity test is positive! ! "。 C. Recording time: fill in the results in the corresponding date column. When two kinds of drug sensitivity tests are conducted on the same day, fill in one result in a box and arrange it vertically. Do more than two kinds of drug sensitivity tests on the same day, and then add them under the column. D. At the time of admission evaluation, ask patients with allergic history and record the way. For example, on the back of the thermometer on the first page, a history of drug allergy is recorded with a red pen, followed by two exclamation marks. For example, "there is a history of penicillin allergy! ! "。 2. 1. 1.5 weeks: fill in the form in blue and black ink. 2. 1. 16 Temperature test requirements:
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