1. medical history report: the nurse in charge briefly describes the patient's condition, including the patient's basic information, chief complaint, current medical history, past history, personal history, etc.
2. Physical examination: report the patient's current vital signs (such as body temperature, blood pressure, heart rate, breathing, etc.). ) and the patient's consciousness, complexion, skin, limbs and other activities.
3. Auxiliary examination: introduce the recent relevant examination results of patients, such as laboratory examination and imaging examination.
4. Nursing problems: analyze the nursing problems of patients, including physical, psychological and social problems.
5. Nursing measures: According to the patient's nursing problems, introduce the nursing measures that have been taken or planned, including medication, nursing operation, health education, etc.
6. Efficacy evaluation: evaluate the therapeutic effect of patients, including the improvement of their condition and the degree of solving nursing problems.
7. Health education: Health education for patients and their families, including disease knowledge, treatment principles, life adjustment, rehabilitation exercise, etc.
8. Case discussion: In the process of ward rounds, medical staff can be organized to discuss cases, so as to improve the quality of nursing and enhance the professional level of medical staff.
8. Nursing records: After the rounds, the nurse in charge needs to record the contents of rounds completely and accurately on the nursing record sheet, so as to provide reference for the follow-up nursing work.