1. Patient information: The report first needs to include general information of the patient, such as name, gender, age, hospitalization number, admission date and other basic information.
2. Infusion situation: indicate whether the patient has used infusion. If the patient does not use an infusion card, it can simply indicate that the patient has not received any infusion treatment.
3. Diagnosis and treatment: This part needs to explain the main diagnosis and treatment measures of the patient, such as whether the patient has received medication and surgery. At the same time, it is also necessary to explain the changes of symptoms and signs of patients and the therapeutic effect.
4. Nursing and observation: This part needs to explain the patient's nursing and observation. For example, whether the nurse regularly measures the patient's temperature, pulse and breathing. At the same time, if abnormal conditions, such as fever and dyspnea, are found in the nursing process, they should be recorded in time and corresponding treatment measures should be taken.
In short, if the patient does not use the infusion card, the report should focus on the treatment, care and observation of the patient. It is necessary to describe the patient in detail according to the specific situation, pay attention to the changes of the condition, and take effective nursing and treatment measures in time.