2. The nursing record sheet must be written and signed by a nurse with a practice license. Unlicensed personnel can't write or sign it alone. The nursing record sheet written by practice nurses and undocumented personnel must be reviewed and modified by nurses with a practice license and signed with diagonal lines. Unlicensed personnel sign denominator and certified personnel sign numerator.

3. Time writing: It should be the time for the writer to start writing, not in advance or later. Be realistic and write the date only once a day, and only write the specific time to others.

4. Format writing: leave two words blank at the beginning of the first time or the course of the disease, and leave half a word blank after writing. There should be two blank words after signing.

5, unified use of pens or signature pens, unified color, a nursing record sheet can not appear dark blue, light blue, dark red, light red handwriting. Keep the handwriting beautiful. Use blue pen from 7: 00 am to 6: 59 am and red pen from 7: 00 pm to 6: 59 pm. The handwriting should be neat, the font size should be consistent as far as possible, the handwriting should be clear and difficult to identify, and even the signature should be unified. It is not allowed to act or alter it at will. If there is a typo, draw a double horizontal line above the typo with the original pen, and write the correct word on it, without one or two typos. Three changes to a page should be rewritten, and the original copy should be kept and put into the medical record together. Scraping, pasting and smearing are not allowed to cover up or remove the original handwriting, especially if the key data are altered or unclear, such as the patient's heart rate, blood pressure and time of death during rescue, which is easy to cause controversy in law.

6, nursing records should be stored in the medical record folder, after writing, so as to avoid splashing water stains, stains.

7. In principle, the recording frequency should be recorded in time with the change of illness. In general, primary care should be recorded at least once a day, secondary care at least once every three days, and tertiary care at least once a week.

8. The diagnosis in nursing records should be written in words as far as possible. If it is special and truly international, it can be written in symbols, but it must be consistent with medical care.

9. In the aspect of page arrangement of nursing records, critical and nursing records should be arranged continuously when they are transmitted to each other, and there is no need to edit the page again.

10, the first course, the course of each page and the discharge record should be checked and signed by the head nurse within 24 hours.

1 1. All figures have Arabic numerals and recognized English abbreviations.