2.1 Admission patient evaluation form (i.e., the homepage of the nursing medical record): After the patient is admitted, the nurse will ask about the medical history by talking to the patient or family members, nursing physical examination and condition observation, and reviewing outpatient medical records and examination results. Collect information related to the patient's disease. These materials mainly include:
2.1. l General information of the patient: such as name, gender, age, occupation, ethnicity, marriage, education level, admission time, and admission method.
2.1.2 Admission diagnosis and data collection time
2.1.3 Nursing physical examination: such as body temperature, pulse, respiration, blood pressure, weight, consciousness, expression, whole body Nutrition, skin and mucous membranes, limb activities, allergic history, and psychological state.
2.1.4 Living habits: such as diet, sleep, urinary and defecation habits, and hobbies.
2.1.5 Summary of medical history: Briefly describe the onset process, out-of-hospital diagnosis and treatment, and the purpose of admission.
The above information must be reliable, the record should be comprehensive, accurate, and realistic. The first page should be completed by shift, that is, which shift the patient comes from. Completed by the nurse on duty.
2.2 Nursing Record Form (PIO): It is the core part of the nursing record. The nursing recording process should reflect dynamic changes, that is, recorded in PIO mode. P-Problem (problem), I-intervention
2.2.1 Writing format : Write the year, month, and day at the top of the first nursing course record. Start a new line with two blank spaces and start writing the patient's condition on the first day of admission. Describe the patient's general condition, including psychological state, awareness of the condition, and nursing problems observed. Prioritize and write down the nursing problems to be solved that day and the nursing measures taken, including psychological state analysis and the cooperation of family members. At the same time, the hospital education situation should also be recorded. After recording, sign your full name on the right side of a new line.
2.2.2 The nursing process is being recorded. It is necessary to avoid repeatedly recording the same nursing problems without evaluating the effects of nursing measures. For example, the nurse on the night shift recorded that her body temperature reached 38°C at 6pm, and without special treatment, her body temperature reached 38°C at 7pm. 5℃, follow the doctor's advice and intramuscularly inject 5 mg of dexamethasone... Repeatedly record the course of the disease several times. We understand that it is enough to summarize the course of the disease before handing over, especially to reflect the nursing methods instead of just following the doctor's orders.
2.2.3 During the recording process, the physical and mental changes of the patient should be reflected, and the content of health education should be appropriately recorded. In addition, nursing rounds should be reflected. For example, the head nurse conducts morning ward rounds, discusses nursing medical records, and conducts nursing quality inspections organized by the nursing department. Patient care needs to be documented.
2.2.4 The nursing record sheet should echo back and forth, that is, the effect evaluation of the previous nursing problems, which may be short-term or long-term, must be explained according to the situation. The nursing record on the day before discharge briefly summarizes the patient's current condition, mainly to evaluate the effect of nursing methods on the patient's recovery, or to state the reason for discharge. Only in this way can the nursing record be complete from beginning to end.
2.2.5 The relevant contents of the nursing record sheet must be consistent with the medical records and cannot be tampered with to avoid legal disputes.
The nursing record sheet (PIO) is the essence of the overall nursing record. It best reflects the quality and value of nursing work and should be recorded carefully.
3. Discharge guidance: the same format as medical records and discharge records, including name, gender, age, department, ward, hospital date, discharge date, length of stay, admission diagnosis, discharge diagnosis and treatment effect , and finally the discharge instructions, with the signatures of the head nurse and responsible nurse in the lower right corner.
Discharge instructions are written one day before the patient is discharged, in two copies (the patient takes one copy with him). The instructions include diet, rest, medication, and review based on the patient's different diseases, psychology, treatment and care conditions, and living habits. and knowledge on preventive health care related to diseases. Try to be as specific as possible, don't just write about principles. It varies from person to person. It cannot be cookie-cutter or formulaic.
4. Precautions related to writing nursing medical records:
4.1 When writing nursing medical records for the first time, the head nurse should make overall arrangements, divide the work reasonably, and select experienced and senior nurses. The teacher writes, and the head nurse should provide guidance to ensure the quality of medical records.
4.2 The nursing process of critically ill and rescue patients should be recorded at any time, and that of ordinary patients should be recorded according to the situation.
4.3 After writing the nursing medical record, cancel the shift handover report to reduce duplication of work. Use oral narration for shift handover in the morning meeting, and the key points should be highlighted and organized.