The nursing record sheet is an objective record of the nursing process of the patient during hospitalization by the nurse based on the doctor's orders and condition. The nursing record is divided into general patient nursing records and critical patient nursing records. Writing nursing records is a very important task in our nursing work. Nursing records are legally binding and are very important legal documents in many medical disputes. Writing nursing records well is also very important for our nurses to protect themselves. In terms of writing, although it is very annoying when writing, and we are still in the exploratory stage in many aspects of writing content, we will now excerpt some of the contents from the "Nursing Document Writing Template" here, although these contents may be for everyone Everyone is already familiar with it, but I hope it can help those friends who don’t have this information yet. And I will also collect some knowledge about nursing medical record writing. I hope that friends who have experience in nursing medical record writing will also contribute their own experience and share it with everyone. General patient care records General patient care records refer to the nurses’ objective records of the care process of general patients during their hospitalization based on medical orders and conditions. The content includes patient name, department, hospitalization record number, bed number, page number, record date and time, condition observation, nursing measures and effects, nurse signature, etc. Writing requirements: 1. Record with blue and black ink pen. The writing should be neat, clear handwriting, accurate expression, smooth sentences, correct punctuation, and no alteration is allowed. If there is a writing error, double lines should be marked on the typo, and the original record should be kept clear and legible. If there are more than three corrections on one page, they should be rewritten. The copyist should keep the original manuscript and put it into the medical record. The modified parts should be marked in blue and black. For ink signatures, the original handwriting must not be covered or removed by scraping, gluing, blackening or other methods. 2. The lintel content includes: department, bed number, name, gender, hospitalization record number, page number, and record date. 3. Record in the condition column: The observed objective changes in condition should be recorded in timely order according to date and time, and the nursing measures and effects taken should be recorded at the same time. Record the date in the top box, and the time should be specific to the minute. Write the observation content, nursing measures and effects in another line of space, and sign the full name of the nurse at the end of another line. 4. Determine the recording frequency according to the patient's condition: (1) First-level nursing records at least twice a week, and second- and third-level nursing records once a week. (2) Newly admitted patients should write nursing records for each shift, emergency patients should record for 2 consecutive days, and postoperative patients should record for three days. Record at least once per shift (3) If the patient is seriously ill, there must be a record of post-operative care on the day of the operation. If the patient's condition changes, the nurse who transfers the patient should record it at any time according to the doctor's instructions. (4) If the patient's temperature is above 38.5 degrees, the shift should be continued until the patient's temperature is normal, and changes in the patient's condition should be recorded at any time. 5. The nurse signs the full name after recording. Unregistered nurses cannot sign alone. After signing, the registered nurse should review, modify and sign. The signature format is: registered nurse.internship.nurse on probation. Critically ill patient care records Critically ill patient care records refer to nurses’ objective records of the care process of critically ill patients during their hospitalization based on medical orders and conditions. Critical patient records should be written according to the nursing characteristics of the corresponding specialty. The content includes the patient's name, department, hospitalization record number, bed number, page number, recording date and time, amount of fluid taken in and out, body temperature, pulse, respiration, blood pressure and other condition observations, nursing measures and effects, nurse signature, etc. Recording times should be specified to the minute. Writing requirements: 1. After the doctor issues a critical care order, the nurse should promptly record the care of the critical care patient. 2. Record with blue and black ink pen during the day and night. Other requirements are the same as general nursing records. 3. The content of the lintel includes: department, bed number, name, hospitalization record number, page number, and date of hospitalization. 4. Record the intake and intake in detail: (1) Each meal of food should be recorded in the input column. The water content of the food and the amount of water consumed each time should be recorded accurately in a timely manner. (2) Infusion and blood transfusion: Accurately record the liquid, drug name and blood input volume at the corresponding time. (3) Output: Including urine output, vomiting amount, stool, and various drainage volumes. In addition to recording milliliters, their color and nature must also be recorded in the condition column. 5. Record vital signs in detail and accurately. The recording time should be specific to the minute. Generally, it should be recorded at least every 4 hours. The body temperature should be measured at least 4 times a day if there are no special changes. Changes in the condition should be recorded at any time. 6. The patient's condition observation, nursing measures and effects within 24 hours should be objectively recorded in the condition column. Surgery patients should also record the anesthesia method, name of the operation, status of the patient's return to the ward, wound condition, drainage status, etc. 7. Nursing records for critically ill patients should be written according to the nursing characteristics of the specialty.

Writing must be objective, true, accurate, timely and complete