What is the writing sample for "General Nursing Record Sheet"?

Nursing records are the nurse’s reflection of the patient’s vital signs during the medical care activities, the specific manifestation of the implementation of various medical measures and the record of the results. Nursing records not only reflect the quality of medical care, academic and management levels of the hospital, but also provide valuable basic information for medical care, teaching, and scientific research. They are also important evidence materials when medical disputes are involved, and are an important basis for determining legal liability. However, for a long time, due to the influence of the traditional biomedical model and functional nursing, the content of nursing records is not standardized, and the quality of nursing records is not guaranteed. The author below summarizes the research data on nursing records for reference by colleagues. \x0d\\x0d\1The significance of writing nursing records\x0d\\x0d\Nursing records are an important part of medical nursing documents. It reflects all the medical care of the patient during his illness and hospitalization, and embodies the connotation of nursing work. It is an indispensable and important data for clinical teaching and scientific research work and has strong legal effect. Nursing records strengthen the communication between doctors and patients, improve the nurses' abilities in observation, communication, writing and other aspects, enhance their sense of responsibility, and improve the quality of care. \x0d\\x0d\2 Contents written in nursing records\x0d\\x0d\2.1 Admission evaluation form After the patient is admitted, the nurse will ask about the medical history by talking to family members or relatives, nursing physical examination and condition observation, reading outpatient medical records and examination results, etc. , collect information related to the patient's disease. This information mainly includes: (1) General information of the patient: such as name, gender, age, occupation, ethnicity, marriage, education level, admission time, and admission method. (2) Admission diagnosis and data collection time. (3) Nursing physical examination: such as body temperature, pulse, respiration, blood pressure, weight, consciousness, expression, systemic nutrition, skin and mucous membranes, limb activities, allergic history, and psychological state. (4) Living habits: such as diet, sleep, urinary and defecation habits, and hobbies. (5) Medical history: briefly describe the onset process, out-of-hospital diagnosis and treatment, and the purpose of admission. The above information must be reliable, and the records must be comprehensive, accurate, and realistic. The first page should be completed by the shift, that is, which shift the patients come from, and the nurse on duty should complete it. \x0d\\x0d\2.2 Nursing Record Order (PIO) PIO is the core part of the nursing record. The nursing recording process reflects dynamic changes, that is, it is recorded in PIO mode. P-problem (problem), I-intervention (measure), O-outcome (result). This nursing sheet integrates the nursing plan, nursing measures, basis for the measures, and effect evaluation, making it easier to record. During the writing process, there is no need to emphasize listing the nursing diagnosis, measures, and results separately. Instead, it is reflected in the record of the nursing process. The following points: (1) Nursing records are objective records of the nursing process of patients during hospitalization by nurses based on doctor's orders and conditions, to avoid repeatedly recording the same nursing problems without evaluating the effects of nursing measures. According to the condition, the patient's subjective symptoms, emotions, psychology, diet, sleep, urination and defecation conditions, as well as the patient's new symptoms and signs, etc. are recorded in a targeted manner. Carefully and truthfully record the treatment measures implemented for the condition, the effects of the nursing measures, and the adverse reactions. (2) Record the positive results of laboratory tests in order to observe the condition, but do not record the content of subjective analysis. The content of nursing operations should record the operation time, key steps; the patient's condition during the operation, and the operator's signature. (3) During temporary administration, the drug name, dosage, and patient’s reaction after taking the drug should be recorded. (4) Emphasis on vital signs as the focus of recording. If the doctor does not give treatment advice when the patient has symptoms and orders "observation", "observation" is also a doctor's order. The nurse should record the doctor's full name and the content of the observation ordered. (5) On the day or the day before the patient is discharged, the patient's condition and outcome should be stated, as well as the health issues that need to be explained to the patient and their family members. (6) The patient's preoperative preparation, changes in condition, etc. should be recorded one day before surgery; records should be recorded in a timely manner on the day of surgery, at least once per shift in the first three days after surgery, and changes in condition should be recorded at any time. On the day of discharge, record the postoperative wound condition of the surgical patient, whether there is a drainage tube, whether the sutures have been removed, and the health education and guidance content that needs to be explained to the patient and their family members.

\x0d\\x0d\3Discharge instructions\x0d\\x0d\Discharge instructions are written one day before the patient is discharged, in duplicate (the patient takes one copy with him), and are based on the patient's different diseases, psychology, treatment and care conditions, and living habits , Guidance includes diet, rest, medication, review, and disease prevention and health care knowledge and related precautions. Try to be as specific as possible, don't just write principled words, it should be different for each person, and it can't be stereotyped or stereotyped. \x0d\\x0d\4 Precautions related to writing nursing records\x0d\\x0d\(1) Writing format: Write the year, month, and day at the top of the first nursing course record, and start a new line with two spaces and start writing the first day of the patient's admission. daily situation, describe the patient's general condition, including psychological state, and degree of awareness of the condition. Based on the priorities of observed nursing problems, write down the nursing problems to be solved that day and the nursing measures taken, including analysis of the psychological state and family members. cooperation, and also record the admission education situation. After recording, sign your full name on the right side of a new line. (2) In nursing course records, it is necessary to avoid repeatedly recording the same nursing issues without evaluating the effects of nursing measures. It is necessary to reflect more nursing methods instead of just following doctor's orders. (3) The patient's physical and mental changes should be reflected in the nursing recording process, and the content of health education should be appropriately recorded. In addition, nursing rounds, nursing case discussions, and patient care content must be accurately recorded. (4) The nursing record sheet should be echoed back and forth, that is, the effect evaluation of the previous nursing problems may be short-term or long-term, and the reasons must be explained according to the situation. (5) The relevant contents of the nursing record sheet must be consistent with the medical records, and there must be no discrepancies to avoid legal disputes. (6) When writing the nursing medical record for the first time, the head nurse should make overall arrangements, divide the work reasonably, and select experienced and senior nurses to write it. The head nurse should provide guidance to ensure the quality of the medical record. (7) The nursing process of critical and rescue patients is recorded at any time, and that of ordinary patients is recorded according to the situation. First-level nursing records are recorded every day, second-level nursing care records are recorded every 2 to 3 days, and third-level nursing care records are recorded every 3 to 5 days. \x0d\\x0d\5 Problems and Countermeasures in Nursing Records\x0d\\x0d\5.1 Problems\x0d\\x0d\5.1.1 Nursing records cannot reflect the dynamic process of nursing Nursing records are part of the hospitalization medical record, but the nursing records are Phased nursing records are less summative. At present, there is no national unified standard for nursing records, and the frequency of nursing care has not been determined. Most nurses only record the condition records and nursing measures on a certain day and at a certain time. Such nursing records cannot fully reflect the dynamic process of nursing. \x0d\\x0d\5.1.2 Nursing records cannot reflect nursing behaviors. The contents of nursing records do not highlight the characteristics of nursing profession. Most of the contents recorded by nurses are the patient’s condition and the contents of medical orders, resulting in duplication of medical contents. However, after the nurses implement nursing measures, The nursing effects and observed conditions are not reflected in the nursing records, and the nursing records cannot truly reflect the nursing behavior. For example, for patients with abdominal puncture, if the nurse described in the nursing record that the operation was smooth and the condition was stable, the nurse should not record it, because the nurse did not participate in the operation, and the nurse had no knowledge of the operation name, time, anesthesia method, and the time to wake up from anesthesia. , puncture local conditions, vital signs and precautions and other records are often incomplete. \x0d\\x0d\5.1.3 Incomplete nursing records Some nurses do not have strong awareness of recording at any time. Temporary nursing records are incomplete. Nurses only record mechanically in accordance with relevant regulations. Temporary condition observations, nursing measures taken and nursing effects are There are few records or omissions, and this phenomenon occurs more often among night shift nurses. For example, a patient with upper gastrointestinal bleeding developed nausea, palpitation, discomfort, and irritability one night one week after the bleeding stopped. The nurse on duty did not make a nursing record, but only verbally explained it to the nurse on the next shift. However, on the next shift, the patient suddenly Vomiting blood, this situation illustrates the negligence and defects in the nursing records, which may cause unnecessary medical disputes. \x0d\\x0d\5.1.4 Poor continuity of nursing records There is a shortage of nurses in most hospitals in our country. Nurses are busy with treatment and have no time to observe the patient's condition and write medical records, so nursing records are rarely or even not recorded. Resulting in incomplete nursing records. It is necessary to reflect the continuity of care, especially if the patient's treatment and nursing measures in the previous shift have results in the next shift, the patient's reaction process and change results must be accurately recorded in the next shift. Sometimes it is necessary to record the results in several consecutive shifts. . Some nurses only record the prescribed nursing frequency and do not record continuously according to the specific situation.

\x0d\\x0d\5.1.5 Nursing records do not reflect individualized care and disease-based care. The contents of nursing records of the same specialty are roughly the same, and only reflect disease-specific care, but do not reflect individualized care and care based on needs. The reasons for this phenomenon are: first, the nurses' professional level is low and they cannot find the focus of care; second, the nurses rely too much on accompanying people and do not observe in person; third, they only follow the nursing routine of the disease and lack innovation. , causing the nursing records of a disease to be basically the same and not reflecting differences in disease types and individual differences. \x0d\\x0d\5.2 Countermeasures\x0d\\x0d\5.2.1 Enhance the legal awareness of nursing staff and improve the quality of care. After the implementation of the "Medical Accident Handling Regulations" and other regulations on September 1, 2002, the content of nursing records Both nurses and writers have put forward strict requirements. There is an urgent need to improve the quality of nurses in all aspects. Nurses should be encouraged to participate in various forms of learning to improve their own standards. Nurses must be realistic when writing nursing records and strengthen nurses' legal knowledge learning. , helps nurses analyze the legal relationship between nursing errors, accidents and nursing records, so that nurses can fully realize the important role of nursing records in providing evidence for medical disputes, and establish the concept that prevention of medical disputes is the most important. \x0d\\x0d\5.2.2 Standardize management and ensure that nursing records are kept relatively fixed, so that each patient has his or her own fixed bed nurse. The bed nurse is responsible for writing periodic daily care records, and the nurse on duty is responsible for Write interim care notes. \x0d\\x0d\5.2.3 Reasonably arrange shifts to ensure that bed nurses have continuous contact with the patients in their care, so as to comprehensively and systematically collect patient information and summarize nursing records. \x0d\\x0d\5.2.4 Standardize the writing procedures of nursing records according to the characteristics of the specialty. Carry out key observations, key care, and key records of each patient's nursing care, fully reflecting the nursing records of individual care and need-based care. \x0d\\x0d\5.2.5 Strengthen professional learning and improve the quality of nurses themselves. For a long time, the nursing team has been at different levels and has an unreasonable knowledge structure. Most of them are at the technical secondary school level, with narrow knowledge and communication barriers. So that it cannot meet the health needs of patients and their families. Therefore, it is particularly important for nurses to carry out continuing education. In addition to rich professional basic knowledge, they must also master relevant humanities knowledge, improve their own quality, and provide patients with high-quality services. care. \x0d\\x0d\5.2.6 Strengthen the quality control of nursing record writing. Quality control personnel should conduct irregular inspections to ensure the quality of nursing record writing. \x0d\\x0d\In short, nursing records are the essence of overall nursing work. They can best reflect the quality and value of nursing work and must be recorded carefully. General nursing record sheet writing sample

Nursing record is the nurse’s reflection of the patient’s

vital signs

and the implementation of various medical measures during the medical care activities. The embodiment of a situation and the recording of its results. Nursing records can not only reflect the quality of medical care, academic and management levels of the hospital, but also provide valuable basic information for medical treatment, teaching and scientific research. They are also important evidence materials when medical disputes are involved, and are the basis for judgment

Legal An important basis for responsibility

. However, for a long time, due to the influence of the traditional biomedical model and functional nursing, the content of nursing records is not standardized, and the quality of nursing records is not guaranteed. The author below summarizes the research data on nursing records for reference by colleagues.

1 The significance of writing nursing records

Nursing records are an important part of medical nursing documents. They reflect all the medical care of the patient during his illness and hospitalization, and reflect the importance of nursing work. The connotation is an indispensable and important material for clinical teaching and scientific research work, and has strong legal effect. Nursing records strengthen the communication between doctors and patients, improve the nurses' abilities in observation, communication, writing and other aspects, enhance

sense of responsibility

, and improve the quality of nursing care.

2 Contents written in nursing records

2.1 Admission evaluation form After the patient is admitted, the nurse will ask about the medical history, nursing physical examination and condition observation, and read the outpatient clinic

Medical records

Collect information related to the patient's disease through methods such as medical records and examination results.

This information mainly includes: (1) General information of the patient: such as name, gender, age, occupation, ethnicity, marriage, education level, admission time, and admission method. (2) Admission diagnosis and data collection time. (3) Nursing physical examination: such as body temperature, pulse, respiration, blood pressure, weight, consciousness, expression, systemic nutrition, skin and mucous membranes, limb activities, allergic history, and psychological state. (4) Living habits: such as diet, sleep, urinary and defecation habits, and hobbies. (5) Medical history: briefly describe the onset process, out-of-hospital diagnosis and treatment, and the purpose of admission. The above information must be reliable, and the records must be comprehensive, accurate, and realistic. The first page should be completed by the shift, that is, which shift the patients come from, and the nurse on duty should complete it.

2.2 Nursing Record Order (PIO) PIO is the core part of the nursing record. The nursing recording process reflects dynamic changes, that is, it is recorded in PIO mode. P-problem (problem), I-intervention (measure), O-outcome (result). This nursing sheet integrates the nursing plan, nursing measures, measure basis, and effect evaluation, making it easier to record. There is no need to emphasize the separation of

nursing diagnosis

, measures, and results during the writing process. Listed, but reflected in the record of the nursing process, specifically the following points: (1) The nursing record is the nurse’s objective record of the patient’s nursing process during the hospitalization according to the doctor’s orders and condition, to avoid recording the same nursing issues repeatedly. There is no evaluation of the effectiveness of nursing measures. According to the condition, the patient's subjective symptoms, emotions, psychology, diet, sleep, urination and defecation conditions, as well as the patient's new symptoms and signs, etc. are recorded in a targeted manner. Carefully and truthfully record the treatment measures implemented for the condition, the effects of the nursing measures and the adverse reactions that occurred

(2) Record the positive results of laboratory examinations

in order to observe the condition, but do not record the content of subjective analysis. The content of nursing operations should record the operation time, key steps; the patient's condition during the operation, and the operator's signature. (3) During temporary administration, the drug name, dosage, and patient’s reaction after taking the drug should be recorded. (4) Emphasis on vital signs as the focus of recording. If the doctor does not give treatment advice when the patient has symptoms and orders "observation", "observation" is also a doctor's order. The nurse should record the doctor's full name and the content of the observation ordered. (5) On the day or the day before the patient is discharged, the patient's condition and outcome should be stated, as well as the health issues that need to be explained to the patient and their family members. (6) The patient's preoperative preparation, changes in condition, etc. should be recorded one day before surgery; records should be recorded in time on the day of surgery, at least once per shift in the first 3 days after surgery, and changes in condition should be recorded at any time. On the day of discharge, record the postoperative wound condition of the surgical patient, whether there is a drainage tube

, whether the sutures have been removed, and the health education and guidance content that needs to be explained to the patient and their family members.

3 Discharge instructions

Discharge instructions should be written one day before the patient is discharged,

in duplicate

(the patient takes one copy with him) (Part 1), based on patients’ different diseases, psychology, treatment and care conditions, and living habits, guidance includes diet, rest, medication, review, and preventive and health care knowledge about related diseases and related precautions. Try to be as specific as possible, don't just write principled words, it should be different for each person, and it can't be stereotyped or stereotyped.

4 Precautions related to writing nursing records

(1) Writing format: Write the year, month, and day at the top of the first nursing course record, and start a new line with two blank spaces to write the patient's admission. On the first day, describe the patient's general situation, including psychological state, and degree of awareness of the condition. Based on the priorities of the observed nursing problems, write down the nursing problems to be solved and the nursing measures taken that day, including analysis of the psychological state. and the cooperation of family members, and also record the admission and education situation. After recording, sign your full name on the right side of a new line. (2) In nursing course records, it is necessary to avoid repeatedly recording the same nursing problems without evaluating the effects of nursing measures. It is necessary to reflect more nursing methods instead of just following doctor's orders. (3) The patient's physical and mental changes should be reflected in the nursing recording process, and the content of health education should be recorded appropriately. In addition, nursing rounds, nursing case discussions, and patient care content must be accurately recorded. (4) The nursing record sheet should be echoed back and forth, that is, the effect evaluation of the previous nursing problems may be short-term or long-term, and the reasons must be explained according to the situation.

(5) The relevant contents of the nursing record sheet must be consistent with the medical records, and there must be no discrepancies to avoid legal disputes. (6) When writing the nursing medical record for the first time, the head nurse should make overall arrangements, divide the work reasonably, and select experienced and senior nurses to write it. The head nurse should provide guidance to ensure the quality of the medical record. (7) The nursing process of critical and rescue patients is recorded at any time, and that of ordinary patients is recorded according to the situation.

First-level care

Record every day, second-level care 2 to 3 days, and third-level care 3 to 5 days.

5 Problems and Countermeasures in Nursing Records

5.1 Problems

5.1.1 Nursing records cannot reflect the dynamic process of nursing. Nursing records are part of the hospitalization record, but The nursing records are staged nursing records with little summary. At present, there is no national unified standard for nursing records, and the frequency of nursing care has not been determined. Most nurses only record the condition records and nursing measures on a certain day and at a certain time. Such nursing records cannot fully reflect the dynamic process of nursing.

5.1.2 Nursing records cannot reflect nursing behavior. The content of nursing records does not highlight the

characteristics of the nursing profession.

The content recorded by most nurses is the patient’s condition and medical instructions. The content is duplicative with medical content, and the nursing effects and observed conditions after the nurse implemented the nursing measures are not reflected in the nursing records, and the nursing records cannot truly reflect the nursing behavior. For example, for patients with abdominal puncture, if the nurse described in the nursing record that the operation was smooth and the condition was stable, the nurse should not record it, because the nurse did not participate in the operation, and the nurse did not know the name, time, and operation of the operation.

Anesthesia

Records such as method of anesthesia, time to wake up from anesthesia, local conditions of puncture, vital signs and precautions are often incomplete.

5.1.3 Incomplete nursing records: Some nurses do not have strong awareness of recording at any time. Temporary nursing records are incomplete. Nurses only mechanically record according to relevant regulations. Temporary condition observations, nursing measures taken and care There are few or no records of effects, and this phenomenon occurs more often among night shift nurses. For example, a patient with upper gastrointestinal bleeding

had nausea, palpitation, discomfort, and irritability one night one week after the bleeding stopped. The nurse on duty did not make a nursing record, but only verbally The patient was handed over to the nurse on the next shift, but the patient suddenly vomited blood in the next shift. This situation illustrates the negligence and defects in the nursing records, which may cause unnecessary medical disputes.

5.1.4 Poor continuity of nursing records. Most hospitals in my country have a shortage of nurses. Nurses are busy with treatment and do not pay attention to observing the patient's condition and writing medical records. Therefore, nursing records are rarely or even not recorded. , resulting in incomplete nursing records. It is necessary to reflect the continuity of care, especially if the patient's treatment and nursing measures in the previous shift have results in the next shift, the patient's reaction process and change results must be accurately recorded in the next shift. Sometimes it is necessary to record the results in several consecutive shifts. . Some nurses only record the prescribed nursing frequency and do not record continuously according to the specific situation.

5.1.5 Nursing records do not reflect individualized care and disease-specific care. The contents of nursing records in the same specialty are roughly the same. They only reflect disease-specific care but do not reflect individualized care and disease-specific care. The reasons for this phenomenon are: first, the nurses’ professional level is low and they cannot find the focus of care; second, the nurses rely too much on accompanying people and do not observe in person; third, they only follow the nursing routine of the disease and lack of care. Innovation results in the nursing records of a disease being basically consistent and not reflecting differences in disease types and individual differences.

5.2 Countermeasures

5.2.1 Enhance the legal awareness of nursing staff and improve the quality of care. The "

Medical Accident Handling Regulations" will be implemented on September 1, 2002. p>

" and other regulations have been implemented, and strict requirements have been put forward for the content and writers of nursing records. There is an urgent need to improve the quality of nurses in all aspects. Nurses should be encouraged to participate in various forms of learning to improve their own standards. Requirements Nurses must seek truth from facts when writing nursing records, strengthen nurses' legal knowledge learning, and help nurses analyze the legal relationship between nursing errors, accidents and nursing records

so that nurses can fully understand Nursing records play an important role in providing evidence for medical disputes and establish the concept that prevention of medical disputes is the most important.

5.2.2 Standardize management and ensure that nursing records are kept relatively fixed, so that each patient has his own fixed bed nurse. The bed nurse is responsible for writing staged daily nursing records, and the nurse on duty Responsible for writing temporary nursing records.

5.2.3 Reasonably arrange shifts to ensure that bed nurses have continuous contact with the patients under their care, so as to comprehensively and systematically collect patient information and summarize nursing records.

5.2.4 Standardize the writing procedures of nursing records according to the characteristics of the specialty. Carry out key observations, key care, and key records of each patient's nursing care, and fully reflect the nursing records that provide care according to individual needs and care according to needs. .

5.2.5 Strengthen professional learning and improve the quality of nurses themselves. For a long time, the nursing team has been at different levels and has an unreasonable knowledge structure. Most of them are at the technical secondary school level, 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 carry out continuing education. In addition to rich professional basic knowledge, they must also master relevant humanities knowledge, improve their own quality, and provide patients with high-quality Quality care.

5.2.6 Strengthen the quality control of nursing record writing. Quality control personnel should check from time to time to ensure the quality of nursing record writing.

In short, nursing records are the essence of overall nursing work. They can best reflect the quality and value of nursing work and must be recorded carefully. How do nurses write rescue records?

How to standardize the writing of nursing rescue records?

Nursing rescue records are a kind of nursing documents. They are written records of objective information of patients formed by nurses during the patient rescue process. It requires Clinical nurses should keep relevant records when rescuing patients, describe in detail the changes in the condition, and accurately record the start and end time of the rescue and the rescue process.

Please click to enter the picture description

In the critical care patient care record sheet, the condition record is very important: on the basis of observation and evaluation, the patient's subjective and objective information is described in words Record the patient's state of consciousness, mental status, body position, general skin condition, instrument setting mode and parameters used, intravenous infusion channels, nasogastric tubes, and drainage tubes

, various pipelines such as urinary catheters and the properties of drainage fluid, preventive measures for complications,

Pressure ulcers

, safety risks such as falls, bed falls, accidents, etc., measures to be taken Nursing measures and effects, etc., and disease records should highlight the characteristics of the specialty.

Specific content of condition record

①Patient’s chief complaint.

②The patient’s symptoms,

positive signs

and other clinical manifestations, psychological and behavioral changes, and important abnormal laboratory tests observed by the nurse.

③Record of treatment, nursing measures and effects after implementation.

④Surgery records.

⑥Specialist nursing records.

⑦Special medication records.

⑧Rescue records.

General patients can follow the regulations to simplify the writing of nursing documents and no longer write nursing records. However, critically ill patients, especially those admitted to the ICU, must write nursing records carefully and carefully. Moreover, if the patient's condition changes suddenly and clinical rescue is performed, not only the doctors must write rescue records, but the nurses must also keep corresponding rescue records.

Notes on writing nursing and rescue records

① The content of supplementary notes on medication and treatment should be consistent with the time and content of the doctor’s supplementary medical orders.

② When making supplementary notes, please pay attention to the fact that the supplementary notes conform to the temporal development sequence and logical relationship of the events. For example, recording should not continue after the "corpse preparation".

③As long as the patient still has a heart rate, the blood pressure is recorded as "unmeasured". If the patient's heart rate is already 0, the blood pressure is recorded as 0.

④ Classification of rescue records: divided into pre-hospital, emergency, and ward rescue records; it can also be divided into CPR first aid records and general rescue records.

Attachment: Common rescue recording mode

x hour x minute: symptoms and signs, such as

difficulty breathing

, sweating profusely , measure

vital signs

or monitor the vital signs, immediately give oxygen according to the condition, establish intravenous access, and notify the doctor at the same time.

x time x Points: Give xxxxx treatment according to the doctor's advice, such as

epinephrine

x mg intravenously.

Record vital signs every 5-10 minutes. After the condition is stable, it can be extended to 10-15 minutes or 30 minutes to record and evaluate the condition.

X hour and minute: Loss of consciousness, unresponsiveness, blood pressure cannot be measured (0 or chest compression blood pressure), heart rate?

Oxygen saturation should be administered to the chest immediately Compression, breathing bag assisted breathing, notification

anesthesia

intubation, connection

ventilator

, xx mode.

x hour x minute: Defibrillation record.

x hour x minute: continuous chest compression, blood pressure cannot be measured, SPO2?

Record medication status. If

cardiopulmonary resuscitation

continues for more than 30 minutes without vital signs, the doctor will judge and re-evaluate the five indicators of cardiopulmonary resuscitation (carotid artery fluctuations, heart sounds, respiration, heartbeat, and blood pressure). Whether to stop rescue.

Record: After continuing cardiopulmonary resuscitation for xx minutes, there was still no spontaneous breathing and heartbeat, and he was declared dead.