2, unified use of pens or signature pens, unified color, a nursing record sheet can not appear dark blue, light blue, dark red, light red handwriting. Keep the handwriting beautiful.
3. Use blue pen from 7: 00 a.m. to 6: 59 p.m. and red pen from 7: 00 p.m. to 6: 59 p.m., with neat handwriting, consistent font size and clear handwriting. It is difficult to identify, even the signature should be unified, and it cannot be arbitrarily altered.
If there is a typo, draw a double horizontal line above the typo with the original pen and write the correct word on it. There is no need to copy the whole page just because of one or two typos. Three changes to a page should be rewritten, and the original copy should be kept and put into the medical record together. Scraping, pasting and smearing are not allowed to cover up or remove the original handwriting, especially if the key data are altered or unclear, such as the patient's heart rate, blood pressure and time of death during rescue, which is easy to cause controversy in law.
5, nursing records should be stored in the medical record folder, after writing, so as to avoid splashing water stains, stains.
6. In principle, the recording frequency should be recorded in time with the change of illness. In general, primary care should be recorded at least once a day, secondary care at least once every three days, and tertiary care at least once a week.