1. The time for writing nursing records is minutes. 2. Pay attention to the close connection of records when writing, leave no blank lines, sign the full name, and reflect the nursing behavior with PIO recording ideas. 3, record the positive results of laboratory examination, do not require writing belongs to the content of subjective analysis. 4. Non-invasive surgery, including preoperative preparation, postoperative patient feelings, adverse reactions, changes in vital signs, etc., all need to be recorded in detail. 5. For invasive nursing operation, whether patients choose to do it or not, they should sign the relevant records to show their informed consent. 6. Nursing operation content should record the operation time and key steps, such as extracting gastric juice when inserting gastric tube, patients' situation during operation, operator's signature, etc. 7. Nursing records should include records of non-surgical nursing measures, such as rounds, important educational contents, informative nursing measures, etc. 8, temporary administration should record the name of the drug, dosage, the patient's reaction after taking the drug. 9, when the patient has symptoms, the doctor did not give treatment advice, told "observation is also a doctor's advice, the nurse should record the doctor's full name and inform the observation content. 10, the medical records of critically ill patients should pay special attention to timeliness, including the patient's condition change time, rescue time, medication time, operation time of various medical nursing techniques, consultation time of experts in various subjects, and death time of patients. Specific to minutes. 1 1, the superior head nurse should record the time and rounds. Other specific contents are recorded in another book.