Basic requirements

1. According to the "Basic Standards for Writing Medical Records (2010)" of the Ministry of Health and the "Notice of the General Office of the Ministry of Health on the Implementation of Form-Form Nursing Documents in Medical Institutions" (Health The document "Ban Yi Zheng Fa [2010] No. 125" requires the formulation of this specification.

2. The nursing documents that nurses need to fill out and write include: temperature sheet, doctor's order sheet, critically ill (seriously ill) patient care record sheet, and surgical inventory record sheet.

3. Nursing documents must be written with blue and black or carbon ink pens.

4. Nursing documents must use Arabic numerals to write the date and time. The date is written in year-month-day, and the time is in 24-hour format, down to the minute.

5. The content of nursing documents and records should be objective, true, accurate, timely and standardized.

6. Writing should use Chinese, medical terminology and common foreign abbreviations, with neat writing, clear handwriting, accurate expressions, smooth sentences and correct punctuation.

7. When a typo occurs during writing, use a double line to mark the typo, keep the original record clear and legible, indicate the time of modification, and the signature of the person who modified it. It is not allowed to use scraping, sticking, painting or other methods to cover up or remove the original writing. Superior nursing staff have the responsibility to review and modify records written by subordinate nursing staff.

8. Nursing records written by intern nurses, probation nurses, nurses who have not obtained a nurse qualification certificate or are not registered nurses should be reviewed and signed by nurses with legal practicing qualifications in this medical institution. When modifications are needed, use red Pen modified and signed.

Training nurses can only write nursing documents after their work ability is confirmed by the medical institution receiving further training