Contents written in nursing records
2.1 Admission evaluation form After the patient is admitted, the nurse will ask about the medical history by talking to the family or family members, nursing physical examination and condition observation, reading outpatient medical records and examination results, etc. method to collect data related to the patient's disease. This information mainly includes: (1) General information of the patient: such as name, gender, age, occupation, ethnicity, marriage, education level, admission time, and admission method. (2) Admission diagnosis and data collection time. (3) Nursing physical examination: such as body temperature, pulse, respiration, blood pressure, weight, consciousness, expression, systemic nutrition, skin and mucous membranes, limb activities, allergic history, and psychological state. (4) Living habits: such as diet, sleep, urinary and defecation habits, and hobbies. (5) Medical history: briefly describe the onset process, out-of-hospital diagnosis and treatment, and the purpose of admission. The above information must be reliable, and the records must be comprehensive, accurate, and realistic. The first page should be completed by the shift, that is, which shift the patients come from, and the nurse on duty should complete it.
2.2 Nursing Record Form (PIO) PIO is the core part of the nursing record. The nursing recording process reflects dynamic changes, that is, it is recorded in PIO mode. P-problem (problem), I-intervention (measure), O-outcome (result). This nursing sheet integrates the nursing plan, nursing measures, basis for the measures, and effect evaluation, making it easier to record. During the writing process, there is no need to emphasize listing the nursing diagnosis, measures, and results separately, but it should be reflected in the record of the nursing process. The following points: (1) Nursing records are objective records of the nursing process of patients during hospitalization by nurses based on doctor's orders and conditions, to avoid repeatedly recording the same nursing issues without evaluating the effects of nursing measures. According to the condition, the patient's subjective symptoms, emotions, psychology, diet, sleep, urination and defecation conditions, as well as the patient's new symptoms and signs, etc. are recorded in a targeted manner. Carefully and truthfully record the treatment measures implemented for the condition, the effects of the nursing measures, and the adverse reactions. (2) Record the positive results of laboratory tests in order to observe the condition, but do not record the content of subjective analysis. The content of nursing operations should record the operation time, key steps; the patient's condition during the operation, and the operator's signature. (3) During temporary administration, the name of the drug, dosage, and the patient’s reaction after taking the drug should be recorded. (4) Emphasize vital signs as the focus of recording. If the doctor does not give treatment advice when the patient has symptoms, he orders "observation". "Observation" is also a doctor's order. The nurse should record the doctor's full name and the content of the observation ordered. (5) On the day or the day before the patient is discharged, the patient's condition and outcome should be stated, as well as the health issues that need to be explained to the patient and their family members. (6) The patient's preoperative preparation, changes in condition, etc. should be recorded the day before surgery; records should be made in a timely manner on the day of surgery, at least once per shift in the first 3 days after surgery, and changes in condition should be recorded at any time. On the day of discharge, record the postoperative wound condition of the surgical patient, whether there is a drainage tube, whether the sutures have been removed, and the health education and guidance content that needs to be explained to the patient and their family members.
3 Discharge Instructions
The discharge instructions are written one day before the patient is discharged, in duplicate (the patient takes one copy with him), and are based on the patient's different diseases, psychology, treatment and care conditions. Lifestyle habits include guidance on diet, rest, medication, review, and disease prevention and health care knowledge and related precautions. Try to be as specific as possible, don't just write principled words, it should be different for each person, and it can't be stereotyped or stereotyped.
4 Precautions related to writing nursing records
(1) Writing format: Write the year, month, and day at the top of the first nursing course record, and start a new line with two blank spaces to write the patient's admission. The situation on the first day, describe the patient's general condition, including psychological state, and degree of awareness of the condition. Based on the priorities of the observed nursing problems, write down the nursing problems to be solved and the nursing measures taken that day, including analysis of the psychological state. and the cooperation of family members, and also record the admission education situation. After recording, sign your full name on the right side of a new line. (2) In nursing course records, it is necessary to avoid repeatedly recording the same nursing issues without evaluating the effects of nursing measures. It is necessary to show more nursing methods instead of just following the doctor's orders.
(3) The patient's physical and mental changes should be reflected in the nursing recording process, and the content of health education should be appropriately recorded. In addition, nursing rounds, nursing case discussions, and patient care content must be accurately recorded. (4) The nursing record sheet should echo back and forth, that is, the effect evaluation of the previous nursing problems may be short-term or long-term, and the reasons must be explained according to the situation. (5) The relevant contents of the nursing record sheet must be consistent with the medical records, and there must be no discrepancies to avoid legal disputes. (6) When writing the nursing medical record for the first time, the head nurse should make overall arrangements, divide the work reasonably, and select experienced and senior nurses to write the records. The head nurse should provide guidance to ensure the quality of the medical record. (7) The nursing process of critical and rescue patients is recorded at any time, and that of ordinary patients is recorded according to the situation. First-level nursing records are recorded every day, second-level nursing care records are recorded every 2 to 3 days, and third-level nursing care records are recorded every 3 to 5 days.