1. Patient personal information record: including basic information such as patient's name, gender, age, hospitalization number and admission time.
2. Observation record: according to the doctor's advice, record the patient's vital signs, symptoms, sensory status and other aspects, and record the treatment effect in time.
3. Nursing operation record: If nursing operation is needed, the content and time of nursing operation should be clearly defined in the record.
4. Medical responsibility doctor's diagnosis record: record the diagnosis of patients by medical responsibility doctors to ensure the accuracy of treatment measures.
5. Handover records: When handing over, the observation and treatment records should be handed over to ensure that the patients receive continuous care and care.
6. Record of abnormal conditions: If the patient has abnormal conditions, the abnormal conditions and treatment methods should be recorded in time so as to report to the doctor in time.
7. Rationalization suggestion record: If nurses or other medical personnel find some problems or suggestions during the observation and treatment, they should record them in detail in order to communicate with doctors in time and improve the treatment effect.
The above steps are only one of the daily recording steps of observation and treatment, and the actual practice may change due to hospital regulations or personal experience. Records should be clear, accurate and detailed, and important contents can be marked with different colors, symbols or fonts to facilitate subsequent tracking and processing.