1, nursing records of all inpatients (normal or critical) should be established.
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 the practice nurse and the undocumented personnel must be reviewed and modified by the nurse with a practice license and signed with a slash. The unlicensed personnel sign the denominator and the certified personnel sign the numerator.
3. The writing of time should be the time when the writer begins to write, not in advance or later. Be realistic and write the date only once a day, and only write the specific time to others.
4. The format at the beginning of the first writing or the course of the disease is empty. After writing, half a word can be empty, and there should be two 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.
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.
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 sorting of nursing records, intensive care records 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 course of the first visit, the course of each page and the discharge record should be reviewed and signed by the head nurse within 24 hours.
1 1? All figures have Arabic numerals and recognized English abbreviations.
ECG monitoring is a means to monitor the electrical activity of the heart. Ordinary electrocardiogram can only simply observe and track the short-term ECG activity at that time.