Nursing records are nurses' reflections on patients' vital signs, and are the concrete embodiment of the implementation of various medical measures and their results in the process of medical nursing activities. Nursing records can not only reflect the medical quality, academic and management level of the hospital, but also provide valuable basic data for medical treatment, teaching and scientific research. They are also important evidence when medical disputes are involved and an important basis for judging legal responsibility. However, for a long time, influenced by the traditional biomedical model and functional nursing, the contents of nursing records were not standardized, and the quality of nursing records could not be guaranteed. The author summarizes the research data about nursing records as follows for colleagues' reference.

1 Significance of nursing record writing

Nursing record is an important part of medical nursing documents, which reflects the whole medical nursing situation of patients during illness and hospitalization, embodies the connotation of nursing work, is an indispensable and important material for clinical teaching and scientific research, and has strong legal effect. Nursing records strengthen the communication between doctors and patients, improve the ability of observation, communication and writing of nurses, enhance the sense of responsibility of nurses and improve the quality of nursing.

2 the content of nursing record writing

2. 1 Admission evaluation form After admission, the nurse collected the patient's disease-related information by talking with family members or their families, asking about medical history, nursing physical examination and condition observation, reading outpatient medical records and examination results. These data mainly include: (1) general information of patients, such as name, gender, age, occupation, nationality, marriage, education level, admission time and admission mode. (2) The time of admission diagnosis and data collection. (3) Nursing physical examination: such as temperature, pulse, respiration, blood pressure, weight, consciousness, expression, general nutrition, skin and mucosa, physical activity, allergic history, psychological state, etc. (4) Living habits: such as diet, sleep, defecation habits, hobbies, etc. (5) Medical history: briefly describe the onset process, diagnosis and treatment outside the hospital, and the purpose of admission. The above information should be reliable, the record should be comprehensive, accurate and true, and the home page should be filled in by shifts, that is, which shift of the patient should be filled in by the nurse on duty.

2.2 PIO) The core part of Pio nursing records, the process of nursing records presents dynamic changes, that is, recorded by Pio. P- problem, I- intervention, O- result. This nursing sheet integrates nursing plan, nursing measures, measures basis and effect evaluation, which is more convenient to record. In the process of writing, it is not necessary to list the nursing diagnosis, measures and results separately, but it is reflected in the nursing course record, as follows: (1) Nursing record is an objective record of the nursing process of patients during hospitalization according to the doctor's advice and illness, so as to avoid repeating the same nursing problems without the effect evaluation of nursing measures. According to the patient's condition, record the patient's conscious symptoms, emotions, psychology, diet, sleep, defecation and defecation, as well as the new symptoms and signs of the patient. Seriously and truthfully record the treatment measures implemented according to the condition, the effect after the implementation of nursing measures and adverse reactions. (2) Record the positive results of laboratory examination so as to observe the condition, but don't record the contents of subjective analysis. The content of nursing operation should record the operation time and key steps; The patient's situation during the operation and the signature of the operator. (3) The name, dosage and patient's reaction after taking the medicine should be recorded during temporary administration. (4) Pay attention to vital signs. If the doctor fails to give treatment advice when the patient has symptoms and asks for "observation", "observation" is also a doctor's order. The nurse should record the doctor's full name and the contents of the doctor's orders. (5) On the day of discharge or before discharge 1 day, the patient's condition, prognosis and health problems that need to be explained to patients and their families should be clearly stated. (6) Before the operation 1 day, the patient's preoperative preparation should be recorded, and whether the condition has changed; Records should be made in time on the day of operation, and at least 1 time should be recorded in each shift in the first three days after operation, and the changes of the condition should be recorded at any time. On the day of discharge, record the postoperative wound of the surgical patient, whether there is a drainage tube, whether there is a suture removal, and the contents of health education and guidance that need to be explained to the patient and his family.

3 discharge guidance

The discharge instruction shall be written in duplicate (one copy shall be taken away by the patient) before the patient leaves the hospital 1 day. According to patients' different diseases, psychology, treatment and nursing conditions and living habits, the guidance contents include diet, rest, medication, reexamination, preventive health care knowledge and related matters needing attention. Try to be specific, don't just write principled words, it should vary from person to person, and it can't be stereotyped.

4 writing nursing records related matters needing attention

(1) writing format: write the year, month and day at the head of the first nursing course record, and start writing the first day of the patient's admission in another blank to describe the general situation of the patient, including the psychological state and the degree of understanding of the disease. According to the priorities of the observed nursing problems, write down the nursing problems to be solved and the nursing measures to be taken that day, including the psychological state analysis and the cooperation of family members, and also record the admission education. Record another line and sign your full name on the right. (2) In the process of nursing, it is necessary to avoid repeatedly recording the same nursing problems without evaluating the effect of nursing measures. It is necessary to embody more nursing methods, not just to follow the doctor's advice. (3) The changes in patients' mind and body should be reflected in the process of nursing records, and the contents of health education should be recorded appropriately. In addition, it is necessary to accurately record nursing rounds, nursing case discussions and patient care contents. (4) Nursing records should be consistent, that is, the effect evaluation of some previous nursing problems may be short-term or long-term, and the reasons should be explained according to the situation. (5) The related contents of nursing records should be consistent with the medical records, and there should be no discrepancy, so as not to cause legal disputes. (6) When writing nursing medical records, the head nurse should make an overall arrangement, reasonably divide the work, select experienced senior nurses to write, and the head nurse should give guidance to ensure the quality of medical records. (7) The nursing process of critically ill and rescued patients should be recorded at any time, and ordinary patients should be recorded according to the situation. First-level care is recorded every day, second-level care is recorded for 2 ~ 3 days, and third-level care is recorded for 3 ~ 5 days.

5 Problems and countermeasures of nursing records

5. 1 question

5. 1. 1 Nursing records cannot reflect the dynamic process of nursing. Nursing record is a part of hospital medical records, but it is a phased nursing record with few summaries. At present, there is no unified national standard for nursing records, and the nursing frequency has not been determined. Most nurses only record the illness records and nursing measures on a certain day and time, which can't fully reflect the dynamic process of nursing.

5. 1.2 Nursing records can't reflect nursing behavior. The contents of nursing records did not highlight the characteristics of nursing specialty. Most nurses record the patient's condition and doctor's advice, which leads to duplication with medical content. However, the nursing effect and observation of nurses after implementing nursing measures are not reflected in nursing records, and nursing records can not truly reflect nursing behavior. For example, for patients with abdominal puncture, nurses' descriptions of smooth operation and stable condition should not be recorded, because nurses did not participate in the operation, and nurses' records of operation name, time, anesthesia mode, anesthesia awake time, puncture local conditions, vital signs and matters needing attention often appear incomplete.

5. 1.3 Incomplete nursing records Some nurses have a weak sense of recording at any time, and temporary nursing records are incomplete. Nurses only record according to the relevant regulations mechanically, and the temporary observation of illness, nursing measures taken and nursing effects are less or omitted. This phenomenon is more common among night nurses. For example, 65,438+0 patients with upper gastrointestinal bleeding developed nausea, palpitation, discomfort and irritability one night after 65,438+0 weeks of bleeding cessation. The nurse on duty didn't keep nursing records, but verbally told the next nurse that the next patient suddenly vomited blood. This situation shows that there are negligence and defects in nursing records, which may easily lead to unnecessary medical disputes.

5. 1.4 The continuity of nursing records is poor. Most hospitals in China have a shortage of nurses. Nurses are busy with treatment and have no time to observe patients and write medical records, so nursing records are not recorded, or even recorded, which leads to imperfect nursing records. To reflect the continuity of nursing, especially if the patients in the last shift took treatment and nursing measures and the results appeared in the next shift, the next shift should accurately record the patient's reaction process and change results, and sometimes it is necessary to record several shifts continuously. However, some nurses only recorded according to the prescribed nursing frequency, and did not record continuously according to the specific situation.

5. 1.5 The nursing records do not show that the contents of the nursing records of the same specialty are almost the same as those of the nursing due to illness, but only show the nursing due to illness, and do not show the nursing due to people and needs. The reasons for this phenomenon are: first, the professional level of nurses is low, and the focus of nursing can not be found; Second, nurses rely too much on escort and do not observe in person; Third, it only follows the nursing routine of diseases and lacks innovation, which leads to the same nursing records of a disease and cannot reflect the differences between diseases and individuals.

5.2 Countermeasures

5.2. 1 Enhance nurses' legal awareness and improve nursing quality. Since the implementation of "Regulations on Handling Medical Accidents" in September 2002 1, strict requirements have been put forward for the contents and writers of nursing records, and it is urgent to improve the quality of nurses in all aspects. Nurses should be encouraged to participate in various forms of learning to improve their own level, and nurses must be realistic when writing nursing records. Strengthen the study of nurses' legal knowledge, help nurses analyze the legal relationship between nursing errors, accidents and nursing records, make nurses fully realize the important role of nursing records in the proof of medical disputes, and establish the concept that medical disputes should be prevented.

5.2.2 Standardize management and make nursing records carefully, so that each patient has his own fixed-bed nurse, who is responsible for writing periodic daily nursing records and the nurse on duty is responsible for writing temporary nursing records.

5.2.3 Reasonable shift arrangement, ensuring continuous contact between sickbed nurses and patients, comprehensively and systematically collecting patient data, and summarily recording nursing records.

5.2.4 Standardize the writing procedure of nursing records according to the characteristics of the specialty, and focus on observing, nursing and recording the nursing points of each patient, fully reflecting the nursing records of people and needs.

5.2.5 Strengthen professional study and improve the quality of nurses. For a long time, the nursing team has different levels and unreasonable knowledge structure. Most of them are secondary schools, with narrow knowledge and communication barriers, so that they cannot meet the health needs of patients and their families. Therefore, it is particularly important for nurses to continue their re-education and study. In addition to rich professional basic knowledge, we must also master relevant humanistic knowledge to improve our own quality and provide high-quality care for patients.

5.2.6 Quality control personnel who strengthen the writing of nursing records should check regularly to ensure the writing quality of nursing records.

In a word, nursing records are the essence of holistic nursing work, which can best reflect the quality and value of nursing work and must be carefully recorded.