1, nursing documents and records should be objective, true, accurate, timely and complete, and their full names should be signed. 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, and commonly used foreign language abbreviations and names of symptoms, signs and diseases without formal Chinese translation can be used in foreign languages.
3, nursing documents should be written neatly, legible, accurate expression, fluent statements and correct punctuation. When there are typos in the writing process of nurses on duty, double lines with the same color should be used on the typos, and pens with the same color should be used to correct the underlined typos. 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.
4, nursing records written in accordance with the provisions, signed by registered nurses; The contents written by trainee nurses and trainee nurses shall be reviewed, revised and signed by the legal trainee nurses of this medical institution; Nurses who have passed the examination by the nursing department and departments can write nursing medical records independently after being reported to the nursing department for the record. Those who fail the examination shall be reviewed, revised and signed by the teaching nurses who are legally practicing in this medical institution.
5, the superior nursing staff has the responsibility 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 modification time limit is within 72 hours. Keep the original records clear and easy to read.
6, because of the rescue of critically ill patients, failed to write nursing records in time, should be truthfully fill in the records in time within 6 hours after the rescue, and make records.
7. The time recorded in the document is recorded in 24 hours Beijing time. The units of measurement used are all legal units of measurement in People's Republic of China (PRC).
8. In order to keep the consistency of medical care records, nurses should communicate with doctors more to avoid unnecessary misunderstandings and disputes.
9. The name and order of the filed nursing documents: surgical patient nursing handover sheet, long-term (temporary) doctor's order record sheet, body temperature sheet, admission nursing evaluation sheet, informed consent sheet of nursing measures, critical care plan sheet, ordinary care record sheet and critical care record sheet (ordinary and critical care record sheets are arranged in chronological order).
Other specialist nursing records (such as brain surgery observation records) and hospitalization health education evaluation records shall be kept with the medical records for a long time. The doctor's advice book and the handover report book shall be kept by the department for three years.
10. The ordering and page numbers of hospitalized and filed medical records meet the requirements.
1 1. The pages of nursing documents are neat and printed clearly. The electronically printed nursing record sheet must be signed by the nurse manually.