Writing methods and specific requirements

(1) A nursing record sheet (general or critical) must be established for all inpatient care records.

(2) The nursing record sheet must be written and fully signed by a nurse with a practicing certificate. Unlicensed personnel cannot write or sign alone. Nursing records written by trainee nurses and unlicensed personnel must be written by a practicing nurse. The certified nursing staff will sign with a slash after reviewing and revising it, the uncertified person will sign in the denominator, and the certified person will sign in the numerator.

(3) Writing of time: It should be the time when the writer picks up the pen and starts writing. It cannot be earlier or later. It must be factual. Only write the date once in a day, and only write the specific time otherwise. .

(4) Format of writing: two characters should be left blank for the first time or at the beginning of the course of the disease, and half a word should be left blank for subsequent writings. The upper and lower lines should not hit the line. There should be a two-word gap after the signature.

(5) Use pens or roller pens in the same color, and no dark blue, light blue, dark red, or light red writing can appear on a nursing record sheet. Keep your writing beautiful and pleasing to the eye. Use a blue pen from 7 a.m. to 6:59 p.m. and a red pen from 7 p.m. to 6:59 a.m. The writing should be neat, the font size should be as consistent as possible, and the handwriting should be clear, not flamboyant and difficult to read, even for signatures. Be neat and consistent, do not act haphazardly, and do not make alterations. If there is a typo, use the original pen to draw a double horizontal line above the typo and write the correct word on top. There is no need to re-copy the entire page because of one or two typos. Three alterations on a page should be rewritten. The copyist should keep the original manuscript and put it into the medical record. The original writing should not be covered or removed by scraping, sticking, painting, etc., especially if the key data is altered or unclear. For example, the patient's heart rate, blood pressure, time of death, etc. during rescue can easily cause legal disputes.

(6) The nursing record sheet should be stored in the medical record folder and returned to its place after writing to avoid water stains and stains.

(7) In principle, the frequency of recording should be recorded in a timely manner as the condition changes. Generally, first-level care records at least once a day, second-level care records at least once every three days, and tertiary care records at least once a week.

(8) The diagnosis in the nursing record should be written in words as much as possible. If there is something special and it is indeed internationally standardized, it can be written in symbols, but it must be consistent with medical treatment.

(9) In terms of sorting the pages of nursing records, critical illness and nursing records should be arranged continuously when transferring between them, and there is no need to re-number pages.

(10) The first course of illness, each page of illness and discharge records must be checked, reviewed and signed by the head nurse 24 hours a day.

(Eleven) numbers must have Arabic numerals and recognized English abbreviations.