PIO is a combination of three words: Problem, Intervention and Outcome. PIO recording principle:

1. Take nursing procedure as the framework.

2. Reflect the whole process and dynamic changes of nursing.

3. The content is concrete, true, timely, complete and coherent.

4. Avoid duplication with medical records, but cooperative problems must be recorded.

Extended information:

PIO nursing sheet integrates nursing plan, nursing measures, measures basis and effect evaluation, which is more convenient to record. In the writing process, it is not necessary to list nursing diagnosis, measures and results separately, but it is reflected in the record of nursing course, as follows:

(1) Nursing record is that nurses treat patients during hospitalization according to doctor's advice and illness.

According to the condition, the patients' conscious symptoms, emotions, psychology, diet, sleep, defecation, and new symptoms and signs were recorded. The treatment measures implemented according to the condition, the effect after the implementation of nursing measures and the adverse reactions are carefully and truthfully recorded.

(2) Record the positive results of laboratory examination so as to observe the illness, but don't record the contents that belong to subjective analysis. The content of nursing operation should record the operation time and key steps; The patient's situation in operation, the operator's signature.

(3) The name of the drug, dosage and patient's reaction after taking the drug should be recorded during temporary administration.

(4) Emphasis on vital signs. If the doctor fails to give treatment advice when the patient has symptoms, he is asked to "observe", and "observe" is also a doctor's order. The nurse should record the doctor's full name and the contents of the doctor's order observation.

(5) The patient's condition, prognosis and health problems that need to be explained to the patient and his family should be clearly stated on the day of discharge or the day before.

(6) The preoperative preparation and whether the patient's condition has changed should be recorded one day before the operation. Records should be made in time on the day of operation, at least once per shift in the first three days after operation, and the changes of illness should be recorded at any time. On the day of discharge, record the postoperative wound of the surgical patient, whether there is drainage tube, whether there is suture removal, and the contents of health education and guidance that need to be explained to the patient and his family.

Baidu Encyclopedia-Nursing Procedures