Today, by standardizing the writing content of nursing records, we help nurses to sort out the ideas and clues of writing nursing records, find ways to improve nursing records, and ensure that nursing records meet the requirements of objective, true, accurate, timely and complete standards, which is conducive to comprehensively improving nursing quality and safeguarding the legitimate rights and interests of themselves and hospitals.
Principles of writing nursing documents
I. General requirements
Objective, accurate, timely, complete, continuous and legal. Content requirements: detailed but appropriate, clear thinking and appropriate words.
Second, objectivity.
It is required to remember what you see, what you do, what you have, and the objective facts, and not stick to finding problems. Don't make subjective analysis of the patient's condition, but record the patient's objective data.
Third, accuracy.
Accurate data is required, and the data of dosage, color of drainage fluid and vital signs should be accurate.
What needs to be recorded accurately?
First, the patient's self-report record
The patient's self-report record belongs to the objective data in the medical record and must be recorded. When writing, in principle, remember the patient's original words and add double quotation marks. If it's sorted, don't put double quotes. Because patients have many dialects, spoken languages or common sayings, it is often impossible to write the full text of patients' original words into your records, so most nursing records are without double quotation marks. But if the record is really the patient's self-reported language, it should be quoted.
Second, the observation and recording of diseases.
Nurses should repeat the same nursing operation every day, and monitor and observe the patient's condition. How should routine observation and nursing items be recorded? If the patient's condition is stable at the time of the first recording, and there are no discomfort symptoms, and the condition is relatively stable at the time of subsequent observation, the recording interval can be appropriately extended, and the observation content can be omitted, but the nursing situation should be recorded and observed on time. If the patient has some abnormalities in the first record, follow-up records should be recorded at any time with the change of illness. For example, when the patient has skin redness, phlebitis, dressing exudation, etc. , what kind of corresponding measures have been taken, and the effect is how, these should be recorded.
When a nurse observes the patient's condition, the contents to be observed include:
First, the complaints of patients and their families and the discomfort of patients;
Second, the observed or checked changes in the patient's condition;
Third, the initial symptoms and complications of various diseases;
Fourth, the symptoms of dysfunction of various organ systems.
Third, continuous nursing records
Nursing records should record the dynamic changes of patients' condition, such as the relief or aggravation of symptoms such as palpitation and precordial pain during hospitalization. Changes of body temperature should be recorded after physical cooling. Patients with drainage tubes should describe the amount, color, nature and abnormal smell of drainage. Patients with indwelling catheter should record their urination after removing the catheter.
Four, nursing measures record
1. Nurses operate independently: lying position, skin care, oral care, perineal care, etc.
2. Carry out the doctor's advice: nursing and treatment measures carried out according to the doctor's advice.
3. Coordination measures: tracheotomy, cardiopulmonary resuscitation, dressing change, etc.
Five, nursing measures:
Refers to the nursing measures that have been implemented. Measures to help patients recover their functions are considered from three aspects: observation of illness, health education and nursing treatment measures: for example, promoting intestinal peristalsis, helping patients turn over three times, sitting up by the bed four times, and teaching patients to take deep breaths every time 15 minutes.
Six, the effect record
Effect refers to the reaction result of patients after receiving treatment or nursing, and the effect observation after taking measures for patients' health problems. Records should be objective evaluation, and subjective judgment language should not be used to describe the treatment and nursing effect. The changes of patients' self-perception, the data of vital signs, and the actual state of observed symptoms and signs were applied.
Seven, health education records
For routine missionary work, you can only write missionary projects without recording specific contents; Education and guidance for patients with unsafe factors should be recorded; "Inform" the special examination, operation, special treatment, nursing measures and medication records; Special missionary projects need to record the mastery of missionary objects, patients or their families; Special notices need to be repeated and demonstrated by patients or their families, so as to understand what the patients and their families have mastered and record it. If they can't master it, they should report it to the relevant personnel in time and record it;
Eight, rotating bed records
Because many medical nursing documents need to write the patient's bed number, doctors should be asked to give instructions for bed transfer, and then nurses should record the patient's bed transfer on the nursing record sheet. Patients who transfer beds should put the original bed number in brackets in the lintel column of nursing records, and then write the new bed number at the back instead of ticking it off. And the nursing record should indicate the time of bed transfer. If you change the nursing record again, you don't need to fill in brackets, just write the new bed number directly.
Seven, leave a record
The purpose of the patient's leave, the approver, the time of returning to the ward, the condition at that time, the situation of the patient leaving the hospital without authorization, especially the situation of not staying in the ward and refusing to accept examination, treatment and nursing, and the time of reporting to the doctor should be recorded. For example, the nursing record is "the patient wants to go out and has been told that it is cold outside, but the patient insists that the patient should wear more clothes when going out". This record will be mistaken for the nurse's permission for the patient to go out. This kind of record is not rigorous, which shows that nurses have weak legal awareness. It should be recorded as "the patient asked to go out and the nurse on duty did not agree." It was found that the patient left the ward at XX and returned at XX.
Eight, turn protection single record
Generally, critically ill patients should be transferred to the special nursing record sheet, and after the termination of critical illness, they should be transferred to the general nursing record sheet and written on the special nursing record sheet or the general nursing record sheet. For example:
1, the patient is in critical condition, and the doctor's advice has informed him that he is in critical condition. The nursing record sheet is changed to the intensive care record sheet. (written on the general nursing record sheet). 2, the patient's condition gradually stabilized, the doctor's advice has stopped critically ill notice, intensive care record sheet into ordinary care record sheet.
3, after admission is a critically ill patient, directly recorded in the intensive care list, and then turn after the condition is stable.
Nine, doctor's advice record
Long-term doctor's advice includes nursing level, nursing routine and observation. It is impossible for a doctor to write all the routine contents on the doctor's advice, but the nursing record sheet should record the important contents of the nursing routine. such as
1. First-class care prescribed by doctors: First-class care requires that patients should be visited once every 15-30 minutes, a visiting card should be established, and the visiting situation and time should be recorded in time and signed.
2. Patients with tracheotomy: Doctors prescribe routine care after tracheotomy, suck sputum every 30 minutes or 2 hours, drop medicine into trachea on time, and do oral care twice a day to prevent respiratory tract infection and oral complications.
3. When doctors observe pain, vaginal bleeding and pay attention to wound bleeding, they must record the observation results.
4, special medication should record the name of the drug, time, dosage, usage and matters needing attention. If nitroglycerin, sodium nitroprusside, mannitol and chemotherapy drugs are used, the drug use should be recorded in detail.
5, the preparation work before the special inspection, should be recorded in detail.
6. When the patient has symptoms, the doctor does not give treatment advice and asks for "observation", which is also the doctor's advice. The nurse should record the doctor's full name and the contents of the doctor's orders. In other words, the nurse should check the doctor's advice and the nursing record of the last shift when writing the nursing record every day, so as to continuously observe the condition and deal with it in time.
Ten, the occurrence and handling of emergencies
Such as missing patients, falling out of bed, committing suicide, refusing treatment or examination, etc. , should be recorded in detail, if necessary, should be signed by the patient or his family.
Eleven, abnormal auxiliary results to inform and record.
Inform patients or their families of the abnormal positive results of auxiliary examination and drug allergy test, and record them.
Frequently asked questions of nursing records
Records lack authenticity:
At present, the task of nursing work is heavy, and some nurses have a weak sense of responsibility and record consciousness. They don't collect medical records seriously, don't go deep into the ward to ask for medical records, sit at the nurse's station and copy the doctor's medical records or write by imagination. In order to cope with the examination, other nurses were forced to complete the task, so they had to be sloppy, make up their own records, and make their own subjective judgments.
Subjective assumptions:
Nurses confuse subjective and objective judgments. The description of patient's chief complaint data is inaccurate. If it is the patient's subjective feeling, it must be marked as "patient's private complaint". For example, patients abuse nurses and dump things casually. The nurse wrote "the patient is mentally abnormal", which is the subjective judgment of the nurse and the wrong record. Nurses should record the patient's abnormal performance, such as "the patient's temperature is high" as a subjective record, and should describe the measured temperature. "The patient sleeps at night." But when recording, try to avoid using unpredictable and ambiguous language, which is of no reference value. Such as: normal, relatively stable condition, high, low, average, generally good, no special discomfort, pain relief, etc.
There are many delegation languages:
For example, he is required to turn over every 2 hours/kloc-0 times, strengthen oral care, keep the sheets clean and dry, and strengthen functional exercise of the affected limb. There seems to be no nurse in nursing, which makes people feel that nurses are taking care of their families. The record is simple and the same. It does not reflect personal care and illness care, and does not reflect specific illness changes and individual differences for different patients and diseases. There are many cliches, which can't reflect specific problems and lose the meaning of records.
This solution does not reflect:
How to solve problems for patients, the psychological perception of patients' main illness and patients' right to know are not reflected. For example, the nursing records of patients with myocardial infarction and patients with cerebral infarction are similar when they are admitted to hospital.
Poor continuity, no dynamic observation record;
Such as stable vital signs, stable blood pressure and vague speech. The condition changes, existing nursing problems and nursing measures of the previous class were not recorded and reflected in the next class. For example, whether the patient can't urinate after extubation, breast pain, and whether the situation has improved after the anus has not been vented, and whether further measures have been taken, it has not been continuously explained.
Nursing records are inconsistent with medical records:
Even out of contact. Especially in the aspect of clinical manifestations and changes of illness, the rescue time, description and records of illness are not rigorous, which leads to inconsistent records, changes of patients' illness, which doctors can't deal with in time and nurses can't record. Doctors are used to writing the time of orders as 8 am, 4 pm, etc. However, the nurse did not carefully check and correct it in time, which led to the inconsistency between the time when the doctor's orders were issued and the time when they were executed. This is due to insufficient communication with nurses and doctors, which leads to inconsistency in patient's condition change time, medication time and treatment time.
The dynamic nursing process is less summative;
Nursing records can't reflect the dynamic process of nursing. Nursing record is a part of hospital medical records, but it is a phased nursing record with few summaries. Most nurses only record the illness records and nursing measures at a certain time on a certain day, which can not fully reflect the dynamic process of nursing.
Can not truly reflect the nursing behavior;
Nursing records can't reflect nursing behavior. The contents of nursing records did not highlight the characteristics of nursing specialty. Most nurses record the patient's condition and the contents of the doctor's advice, resulting in duplication with the medical content. However, the nursing effect and observation of nurses after implementing nursing measures are not reflected in nursing records, which can not truly reflect nursing behavior. For example, for patients with abdominal puncture, nurses' descriptions of smooth operation and stable condition should not be recorded, because nurses did not participate in the operation, and nurses' records of operation name, time, anesthesia mode, anesthesia awake time, puncture local conditions, vital signs and matters needing attention often appear incomplete.
Incomplete nursing records:
Some nurses are not aware of recording at any time, and the temporary nursing records are incomplete. Nurses only record temporary observation, nursing measures and nursing effects at a moderate frequency according to regulations. This phenomenon is more common among night nurses. For example, 1 patients with upper gastrointestinal bleeding, one night after the bleeding stopped 1, have symptoms such as nausea, palpitation, discomfort and irritability. The nurse on duty didn't keep nursing records, but verbally told the next nurse that the next patient suddenly vomited blood. This situation shows that there are negligence and defects in nursing records, which may easily lead to unnecessary medical disputes. Even the next day's supplement can't show the actual record.
Poor continuity of nursing records:
Most hospitals in China have a shortage of nurses. Nurses are busy with treatment and have no time to observe patients and write medical records, so nursing records are not recorded, or even recorded, which leads to imperfect nursing records. To reflect the continuity of nursing, especially if the patients in the last shift took treatment and nursing measures and the results appeared in the next shift, the next shift should accurately record the patient's reaction process and change results, and sometimes it is necessary to record several shifts continuously. However, some nurses only recorded according to the prescribed nursing frequency, and did not record continuously according to the specific situation.
Didn't show concern for people and diseases;
The contents of nursing records in the same specialty are almost the same, which only reflect the nursing due to illness, but not the nursing due to people and needs. The reasons for this phenomenon are: first, the professional level of nurses is low, and the focus of nursing can not be found; Second, nurses rely too much on escort and do not observe in person; Third, it only follows the nursing routine of diseases and lacks innovation, which leads to the same nursing records of a disease and cannot reflect the differences between diseases and individuals.
Irregular writing:
Scribbled handwriting, simplified abbreviation, even alteration, knife scraping, some grammatical errors, logical confusion, the use of non-medical terms, colloquial expression, and great randomness. Such as triple heart, double grams, following the concept, bright.
improve one's method
Strengthen the study of legal knowledge
Raise awareness, strengthen self-protection, organize regular study of institutional laws and regulations, establish legal awareness, make nurses realize that every word, sentence and symbol on the nursing record sheet will become evidence and represent a legal responsibility, improve nurses' understanding of the importance of nursing record sheet, and learn to protect hospitals and medical staff themselves with laws.
Improve observation ability
The head nurse should combine the clinical manifestations of patients, instruct nurses how to observe and record, urge nurses to patrol frequently, go deep into the ward constantly, collect data through observation and inquiry, and strengthen the connotation of nursing records.
Nursing observation and specific nursing activities
Focusing on nursing observation and specific nursing activities, whether nursing work is conscientious or not, in addition to patients' subjective feelings and objective effects, is reflected in whether nursing observation on records is timely and accurate and the degree of specific implementation of nursing measures. Therefore, focusing on nursing observation and specific nursing activities not only conforms to the working principle of seeking truth from facts, but also makes the records more concise, complete and focused.
Strengthen business learning
According to the professional characteristics, continuously improve the professional technical level and standardize the nursing record sheet. Different patients have different nursing priorities, observation priorities and key points, so as to avoid similarities and show care for people and needs. Close observation, diligent thinking and detailed records should be made.
Communication between doctors and nurses to avoid inconsistent records.
Inconsistency of medical records is mainly caused by the mistakes of information sources and doctors and nurses in the process of collecting patient data. Nurses should take the initiative to check with doctors when they find that doctors' records are inconsistent with themselves, so as to avoid conflicts in medical records.
sample
0 1 transfer nursing records
14: 00 The patient was transferred from the internal four departments to our department, carried into the ward on a stretcher, and brought into the indwelling catheter, indwelling gastric tube and trocar from the internal four departments. The patient was unconscious, with edema of face and conjunctiva, and his blood sugar was measured11.1mmol/l, T37.7p92 times /min R2.
02 Transfer out nursing records
T36, P86/min, R20/min, Bp 120/80mmHg. Fluent in speaking, muscular in limbs and intact in skin. ECG monitoring showed that the heart rate was 86 beats/min, arrhythmia and atrial fibrillation. Private prosecution: "flustered, chest tightness." The long-term guided infusion has ended, and he is inhaling oxygen at a speed of 3L/ min. Transfer to cardiology department according to doctor's advice, carry oxygen bag and escort.
03 blood transfusion nursing records
The patient's blood routine return: RBC2.5Hb85, transfusion of 200ml of "O" red blood cells according to the doctor's advice, and temperature measurement before blood transfusion. After the nurses checked XX and XX correctly, they entered it at 3: 20. After 30 minutes, the patient complained of no discomfort, and the number of drops was adjusted to 50 drops/minute. After blood transfusion at 5 o'clock, the patient had no special discomfort.
04 discharge nursing records
Patient XXX, male, XX years old, was admitted to the hospital on X years, X months and X days due to gallstones. Laparoscopic cholecystectomy was performed under general anesthesia on X month and X day, and various nursing measures were implemented after operation. The patient asked to be discharged from the hospital today, and told him to rest more, have a light diet, avoid fat and sweet products, and keep a good mood, so as to facilitate the reconciliation of liver and qi and qi and blood. Patients and their families expressed understanding.
The end—