Methods and specific requirements of single and written nursing records (1) A nursing record sheet (normal or critical) should be established for all inpatients' nursing records. (2) The nursing record sheet must be written and signed by a nurse with a practice license. Unlicensed personnel can't write or sign alone. Nursing records written by practice nurses and undocumented personnel must be reviewed and revised by nurses with practice licenses, and signed diagonally. Undocumented personnel should sign denominator, and certified personnel should sign numerator. (3) Time writing: It should be the time when the writer starts writing, not in advance or later. Be realistic and write the date only once a day, and only write the specific time to others. (4) Format writing: leave two words blank for the first time or at the beginning of the course, and leave another half word blank. There should be two blank words after signing. (5) Use pens or signature pens uniformly, with the same color. There should be no dark blue, light blue, deep red or light red handwriting on the nursing record sheet. Keep the handwriting beautiful. Use blue pen from 7: 00 am to 6: 59 am and red pen from 7: 00 pm to 6: 59 pm. The handwriting should be neat, the font size should be consistent as far as possible, the handwriting should be clear and difficult to identify, and even the signature should be unified. It is not allowed to act or alter it at will. If there is a typo, draw a double horizontal line above the typo with the original pen, and write the correct word on it, without one or two typos. Three changes to a page should be rewritten, and the original copy should be kept and put into the medical record together. Scraping, pasting and smearing are not allowed to cover up or remove the original handwriting, especially if the key data are altered or unclear, such as the patient's heart rate, blood pressure and time of death during rescue, which is easy to cause controversy in law. (6) The nursing record sheet should be stored in the medical record folder and returned after writing, so as to avoid splashing water stains and stains. (seven) the recording frequency in principle with the change of illness in a timely manner. In general, primary care should be recorded at least once a day, secondary care at least once every three days, and tertiary care at least once a week. (eight) the diagnosis in nursing records should be written in words as far as possible. If there are special circumstances and there are international uniform regulations, it can also be written in symbols, but it must be consistent with medical treatment. (9) In the ranking of page numbers of nursing records, the critical and nursing records should be arranged continuously when they are transmitted to each other, and there is no need to re-edit the page numbers. (ten) the course of the first visit, the course of each page and the discharge record should be checked and signed by the head nurse within 24 hours. (11) Numbers are Arabic numerals and recognized English abbreviations. Second, the record content The first nursing record refers to the record of the first nursing process written by the management nurse or the nurse on duty after the patient is admitted to the hospital, which is required to be completed within 4 hours after the patient is admitted to the hospital. The contents of the first nursing record include: 1, admission time, admission mode and diagnosis; 2. Complain about discomfort symptoms; 3, a brief medical history, past history related to this disease; 4. Vital signs; 5. Positive signs obtained from nursing physical examination; 6, self-care situation (including abnormal situation or disability)