The principles for simplifying nursing documents are:

:1 The principles of responsibility, safety and simplification should be followed, and nursing documents should be simplified with legal responsibility and patient safety as the bottom line. Ensure patient safety and perform nursing duties. Use tabular nursing records to ensure that nursing records are true, objective, accurate, timely, complete and standardized. Adjust the content, method, time and place of writing nursing records to ensure that nurses observe and detect changes in the patient's condition in a timely manner, handle and record them effectively, and ensure patient safety and medical care work safety.

2 Use tabular nursing records: Tabular nursing records are recorded in a form, including date, time, vital signs, consciousness, input, output, key observation items, and main nursing measures. , special situation records and nurse signatures, etc. Spaces can be reserved in the form design to allow nurses to decide key observation items and main nursing measures based on the patient's condition. Cancel the health education sheet, turn over card, inspection card, measurement record sheet, etc. All these records can be recorded directly on the form nursing record sheet. To break the concept of general patients and critically ill patients, all inpatients require the observation and care of nurses. Nurses have legal responsibility for all inpatients. Therefore, only nursing records can timely and accurately reflect the development and changes of inpatients' conditions and the nurses' Nursing behavior can ensure patient safety and provide legal evidence for nursing behavior.

3 Nursing records should focus on recording the development and changes of the patient's condition and the entire process of medical care. The content of nursing records should reflect the characteristics, professional connotation and development level of the nursing profession itself. The content of the nursing record is to record what the nurse saw, smelled, heard, measured and did with the patient. From the nursing record, we should see the patient’s key observations and main nursing measures. For example, if the doctor prescribed “5% glucose 250ml + sodium nitroprusside 50mg, 10 ~ 20 ml/h, intravenous drip”, the nursing record should focus on recording. Monitor the patient's blood pressure and adjust the drip rate according to the blood pressure. Avoid light during the infusion process and replace the drug liquid every 4 to 6 hours. If the patient's biochemical test results show hypokalemia, the nurse should observe and record whether the patient has numbness of the limbs, weakness, abdominal distension, constipation, nausea, anorexia, changes in heart rate, etc. If the patient cannot stand and walk, the nurse should record whether anti-fall measures are taken, etc. wait. These observation items and nursing measures should be filled in the blank columns of the tabular nursing record sheet, and recorded in real time by ticking immediately after the observation and care are provided.

4 The content and scope of nursing records should include the following situations: ① When the patient's condition is unstable and the condition changes at any time, the nurse should closely observe and make records. ②After surgical operations, first-level nursing patients with unstable conditions, special patients, such as newborns, elderly high-risk patients, etc., the responsible nurse should observe the condition and take care measures, and keep records. ③ When performing special invasive nursing techniques, the operator records the assessment, notification and effects. ④ When patients receive special drugs or other treatments, they need to be continuously and closely observed and the treatment effects should be accurately recorded. ⑤ After the nurse conducts a special examination on the patient, the observation and nursing measures are in place and the patient is recorded. ⑥Situations where medical orders need to be recorded.

In short, the tabulation of nursing documents has also brought about changes in nursing management methods. Nowadays, when nursing managers inspect nursing work, they should not just check the nursing records, but more importantly, go to the scene to see the nursing work. When evaluating, they should take into account the patient's feelings and needs.