1. Holistic nursing, as a new nursing work mode, is not well understood and its spiritual essence is not fully understood.
2. Nurses don't know enough about the significance of writing holistic nursing records.
3. There is no uniform pattern and writing standard in China.
4. There is a serious shortage of nurses.
5. The professional quality of nursing staff needs to be further improved.
Due to the above factors, the writing level of holistic nursing medical records is not high.
1. Significance of writing holistic nursing records: As far as the medical records of inpatients are concerned, there are medical materials and nursing materials, but the so-called nursing materials are only temperature sheets and doctor's orders. Can these two records reflect the content of nursing work? Obviously not, hospitalized patients should have two medical records, namely, medical records and nursing records, in order to reflect all the medical care of patients during hospitalization. But for a long time, due to the influence of biomedical model and functional nursing. It leads to the lack of complete and systematic nursing records in nursing work. Even the nursing records of responsible nursing are only for examination, and they are not included in the hospital medical records, and the contents are not as comprehensive as the overall nursing medical records.
Truth and perfection.
The implementation, popularization and deepening of holistic nursing has created favorable conditions for writing holistic nursing medical records, opened up new ways for improving the professional level of nursing workers, and is a powerful measure to develop nursing discipline, making nursing work more and more an independent discipline.
Holistic nursing record is an important part of medical nursing documents, which should be included in the management of inpatient medical records and have legal effect. It is a complete record and summary of the overall care of patients' body and mind by the responsible nurses and all other nursing staff. It is an indispensable and important material for clinical teaching and scientific research, and it is also an important symbol to measure the quality of hospital medical care.
2. The content of the holistic nursing record
Holistic nursing records include three parts;
2. 1 Inpatient Evaluation Form (i.e. the first page of nursing records): After the patient is admitted to the hospital, the nurse collects information related to the patient's disease by talking with the patient or his family, asking about the medical history, nursing physical examination and observation of the condition, consulting the outpatient medical records and examination results, etc. This information mainly includes:
2. 1.l General information of patients: such as name, gender, age, occupation, nationality, marriage, education level, admission time and admission mode.
2. 1.2 time of admission diagnosis and data collection
2. 1.3 Nursing physical examination: such as temperature, pulse, respiration, blood pressure, weight, consciousness, expression, general nutrition, skin and mucosa, physical activity, allergic history and psychological state.
2. 1.4 Living habits: such as eating, sleeping, defecation habits and hobbies.
2. 1.5 Summary of medical history: Briefly describe the onset process, diagnosis and treatment outside the hospital, and the purpose of admission.
The above information should be reliable, the records should be comprehensive, accurate and true, and the home page should be filled in according to the class, that is, which class of patients came. To be filled in by the nurse on duty.
2.2 PIO is the core part of nursing medical records, and the process of nursing records should reflect dynamic changes, that is, it should be recorded by PIO. P- problem, I- intervention, O- result. This kind of nursing record sheet integrates the nursing plan, nursing measures, measures basis and effect evaluation in the original responsibility system nursing medical record, which is more convenient to record and write. It is not emphasized to list nursing diagnosis, measures and results separately, but it is reflected in the nursing course record. Everyone has the experience of writing responsibility nursing records, so it should not be difficult to write this kind of nursing records, but we should pay attention to the following points:
2.2. 1 writing format: write the year, month and day of the first nursing course record immediately, and begin to write the first day of the patient's admission, using two spaces to describe the general situation of the patient, including the psychological state and understanding of the disease. According to the priorities of the observed nursing problems, write down the nursing problems that need to be solved and the nursing measures taken that day, including the psychological state analysis and the cooperation of family members, and also record the people's hospital. Record another line and sign your full name on the right.
2.2.2 In the nursing course record. It is necessary to avoid repeatedly recording the same nursing problems without evaluating the effect of nursing measures. For example, the night shift nurse recorded a temperature of 38℃ at 6 pm and reached 38.5℃ at 7 pm without special treatment. According to the doctor's advice, intramuscular injection of dexamethasone 5mg ..............................................................................................................., we realized that it was enough to record the course of the disease summarily before the shift change, especially to reflect more nursing methods, not just to carry out the doctor's advice.
2.2.3 The psychosomatic changes of patients should be reflected in the recording process, and the contents of health education can be properly recorded. In addition, it is necessary to reflect the nursing rounds. For example, the head nurse makes morning rounds, discusses nursing medical records, and checks the nursing quality organized by the nursing department. The nursing contents of patients should be recorded.
2.2.4 Nursing records should be consistent, that is, the effect evaluation of some previous nursing problems may be short-term or long-term, which should be explained according to the situation. The nursing record of the day before discharge briefly summarizes the current situation of patients, mainly to evaluate the effect of using nursing methods to make patients recover, or to state the reasons for discharge. In this way, the nursing record is complete.
2.2.5 The related contents of the nursing record sheet should be consistent with the medical records, and there should be no one, so as not to cause legal disputes.
PIO is the essence of holistic nursing record, which can best reflect the quality and value of nursing work and should be recorded carefully.
3. Discharge guidance: the format is the same as that of the medical record, including name, gender, age, department, ward, admission date, discharge date, hospitalization days, discharge diagnosis and treatment effect, and finally discharge guidance, with the signatures of the head nurse and the responsible nurse in the lower right corner.
The discharge instruction is written in duplicate on the day before the patient leaves the hospital (one copy is taken away by the patient). According to patients' different diseases, psychology, treatment and nursing conditions and living habits, the guidance includes diet, rest, medication, review and related disease prevention and health care knowledge. Try to be specific, don't just write principled words. It varies from person to person. Can't be stereotyped and patterned.
4, writing nursing medical records related matters needing attention:
4. 1 At the beginning of the writing of nursing medical records, the head nurse should make overall arrangement and reasonable division of labor, select experienced senior nurses to write, and the head nurse should give guidance to ensure the quality of medical records.
4.2 The nursing process of critically ill and rescued patients should be recorded at any time, and ordinary patients should be recorded according to the situation.
4.3 After writing the nursing medical records, cancel the shift report, reduce the duplication of work, and adopt dictation in the morning shift meeting, with emphasis and orderliness.
In short, this form of holistic nursing medical record is simple and clear, and it is easy for nurses to master. Moreover, it obviously improves the quality of nursing, facilitates the examination and evaluation of nursing quality, better embodies the holistic nursing service centered on patients, improves the language expression ability and writing level of nurses, and provides good materials for nurses to sum up experience, write papers and design scientific research.