I. Categories of tabular nursing documents According to the requirements of the two notices, the nursing documents that nurses need to fill in and write include: temperature list, doctor's order list, operation inventory record and nursing record of critically ill patients. All nursing documents can be in tabular format.
Second, the content and requirements of nursing documents Nursing documents are an integral part of medical records, and the written content should be organically combined with other medical records, unified with each other, and avoid duplication and contradictions. Writing nursing documents should be objective, true, accurate, timely and standardized.
(1) temperature list. The temperature sheet is mainly used to record the patient's vital signs and related information, including the patient's name, age, sex, subject, bed number, admission date, hospitalization record number (or medical record number), date, hospitalization days, postoperative days, pulse, temperature, respiration, blood pressure, intake and output, defecation times, weight, height, page number, etc.
(2) Long-term medical advice. The contents of the long-term medical order list include the patient's name, department, bed number, inpatient medical record number (or medical record number), start date and time, long-term medical order content, stop date and time, doctor's signature, nurse's signature and page number. Among them, the doctor fills in the start date and time, long-term doctor's advice content, stop date and time. Nurses carry out long-term doctor's orders every day, such as medication list, infusion list and treatment list. , signed by the executive nurse, is not included in the medical record.
(3) temporary medical advice. The contents of the temporary medical order list include the patient's name, department, bed number, inpatient medical record number (or medical record number), date and time, temporary medical order content, doctor's signature, executive nurse's signature, execution time and page number. Among them, the doctor should fill in the contents of the doctor's advice at any time and temporarily; The nurse who executes the temporary doctor's order fills in the execution time and signs it.
(4) Operation inventory record. Operation inventory records include patient's department, name, gender, age, inpatient medical record number (or medical record number), operation date, operation name, blood transfusion, counting and checking the number of various instruments and accessories used in the operation, and signatures of surgical instrument nurses and visiting nurses. After the operation, the operation inventory record should be completed immediately, and signed by the surgical instrument nurse and the visiting nurse.
(5) Nursing records of critically ill patients. The nursing records of critically ill patients are applicable to all critically ill patients, as well as patients whose condition changes and needs monitoring. Nursing records are recorded in the form of nursing records, including the patient's department, surname, age, sex, bed number, hospital medical record number (or medical record number), date of admission, diagnosis, date and time of recording, items observed and monitored according to specialty characteristics, treatment and nursing measures taken, nurse's signature, page number, etc. Nursing records should be designed and written according to the nursing characteristics of the corresponding specialties and based on the principle of simplification and practicality.