Hello! Glad to answer for you! ~ nursing records will be written by interns! Patients with first-class nursing should be signed by the head nurse, and interns should be signed by the teaching teacher when writing nursing records. No nursing record can be signed, otherwise the nursing record will lose its legal effect. How to write (nursing) pathology in practice manual
Hello, dear! The writing of nursing medical records should follow the principle of seeking truth from facts, objectively describe the condition, treatment and nursing process, and cannot be described by the supervisor. Shall not be altered, fraud, should accurately and timely reflect the course of disease. The lintel column of nursing medical records should be filled in completely, including the patient's name, age, gender, hospitalization number and disease diagnosis. The contents of nursing records should describe the etiology, course of disease, treatment, nursing diagnosis and corresponding nursing process.