The important thing of nursing documents is not writing, but how to observe and do it, observe the changes of patients' vital signs and conditions, provide patients with what treatment and appropriate nursing services, and record what we see in a timely, objective, accurate and standardized manner.
A, nursing records should comply with the following basic writing norms:
(1) Nursing documents should be written by registered nurses in the hospital according to the specified contents, and the recorder should be the executor of the recorded contents.
(2) The superior nurses have the responsibility to review and modify the nursing documents written by the junior nurses. Nursing documents written by nursing students, trainee nurses and senior nurses should be reviewed, revised, confirmed and signed by registered nurses in our hospital in the following form: student/teacher).
(3) Paper nursing documents should be written in blue/black or red pen/signature pen as required, and pencils and erasable pens are not allowed.
(4) The date and time in the nursing documents should be Arabic numerals, with a 24-hour system.
(5) The unit of measurement shall be the legal unit of measurement in People's Republic of China (PRC).
(6) Nursing documents should be written in Chinese, and commonly used foreign language abbreviations and names of symptoms, signs and diseases without formal Chinese translation can be used in foreign languages.
(7) Standard medical terms should be used in nursing documents.
(8) When typos appear in the writing process of nursing documents, double horizontal lines with the same color should be crossed out to keep the original records clear and distinguishable, and the modification time and the signature of the modifier should be indicated at the upper right of the last word with errors. The original handwriting shall not be covered or removed by scraping, gluing or painting.
(9) Each page of nursing documents should contain the patient's identity information, such as name, gender, department, hospitalization number/medical record number, etc.
precise
(1) The description of the recorded content shall be clear and accurate, and vague description shall not be used. For example, "drink more water" should be marked as "drink no less than 1000ml within 2 hours.
(2) The recording time should be consistent with the actual execution time; It is consistent with other medical literature, complementary to each other, and there should be no contradiction.
Objective truth
(1) The recorded content should describe the objective information of the patient. The information obtained by nurses through observation, conversation and physical examination should not be subjectively speculated or judged, and forgery is prohibited.
(2) The recorded contents should reflect the real care received by patients, including health education and psychological care.
accomplish
(1) The recorded contents should reflect the change of patients' condition and the dynamic change process of treatment and nursing.
(2) The recorded contents should reflect the whole process of nursing procedure and the thinking and process of solving nursing problems.
Patient-centered
Nursing documents should embody the service concept of taking patients as the center. The contents of the record should reflect the patient's condition changes, health needs and the care given by the nurse.