1, the formula for calculating the qualified rate of writing emergency nursing documents:

Number of qualified nursing documents written/total test score * 100%.

2, the emergency department of nursing documents written content assessment qualified rate:

(1) temperature sheet: used to record the vital signs and related information of patients.

(2) Medical advice: it is divided into long-term medical advice and temporary medical advice.

(3) Operation inventory record: The operation inventory record should be completed immediately after the operation, and signed by the surgical instrument nurse and the visiting nurse.

(4) Nursing records of critically ill patients: Nursing records should be designed and written according to the nursing characteristics of corresponding specialties.

3. The importance of writing qualified nursing documents in emergency department;

(1) Nursing documents are written records formed by nursing staff in the process of nursing.

(2) Nursing record sheet can not only directly reflect the observation ability and professional level of nurses, but also be an objective basis for evaluating nursing quality.

(3) It is a good material for clinical teaching to accumulate information for nursing scientific research.

Basic requirements for writing nursing documents in emergency department;

1、? Nursing records should be objective and true.

Write in blue ink for the day shift and in red ink for the night shift.

2. Medical terms should be used when writing nursing documents.

Commonly used foreign language abbreviations and names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages.

3, nursing documents should be written neatly.

When writing, the expression should be clear and appear in the writing process of the nurse on duty.

4. Correct typos with the same color pen.

Scraping, pasting, smearing and other methods shall not be used to cover or remove the original handwriting, and no more than two places shall be altered on each page. Any numerical error cannot be corrected by the above method.

5, nursing records written by the regulation.

Those who fail the examination shall be reviewed, revised and signed by the teaching nurses who are legally practicing in this medical institution.

6, the superior nursing staff have to review and modify the nursing records written by the lower nursing staff.

When revising, use red pen and double lines, use red pen to revise the crossed-out typos or sentences, and sign the full name and time. The time limit for modification is within 72 hours.