1. Basic information of patients: including basic information such as patient's name, gender, age and hospitalization number, to ensure accuracy.

2. Nursing date and time: record the date and specific time of nursing for subsequent reference and analysis.

3. Nursing content: record the specific content of each nursing in detail, including vital signs monitoring, drug administration, nursing operation, etc. To ensure the completeness and accuracy of the records.

4. Observation of illness: record the observation results of patients' illness, including the changes of consciousness, respiration, heart rate, blood pressure and other indicators, as well as adverse reactions or complications.

5. The phenomenon of doctor's advice execution: record the phenomenon of doctor's advice execution, including administration time, dosage and route. , to ensure that the nursing according to the doctor's advice.

6. Effect evaluation of nursing measures: record the effect evaluation of nursing measures, including the change of patients' condition and the improvement of vital signs, so as to facilitate the evaluation of nursing effect.

7. Handover records: At each handover, the nursing records are handed over in detail to ensure the consistency and accuracy of the information.

8. Signature and date: Every time the nursing record is filled in, the nurse should sign in the corresponding column, and indicate the date and time of filling in, so as to ensure that the responsibility is clear and traceable.