Records must be timely, accurate, true and perfect. The content is concise and to the point, and the application of medical terms is accurate. The handwriting is clear and correct, and shall not be altered. The number of pages in eyebrow column must be filled in completely. 2. Recording method (1) Fill in the eyebrow column with blue-black ink pen: name, ward, bed number, diagnosis, hospitalization number, etc.
7: 00 a.m.-6: 00 p.m. Record with blue-black ink pen. Record in red pen from 6 pm to 7 am.
(2) Subtotal shall be made at 6 o'clock in the afternoon for the day shift (draw a blue horizontal line to summarize in and out during the day), and the night shift nurse shall summarize in and out 24 hours at 7 o'clock in the morning (draw a red horizontal line, and then draw a red horizontal line after summarizing). Fill in the corresponding box of the temperature list with a red pen.
(3) Before the succession, the nurses in each shift should sign the "illness change" column to show their responsibility.
(4) After the patient leaves the hospital, clinical nursing records should be put into the medical records.
(5) Record of liquid inflow and outflow: Some special patients must record the 24-hour liquid intake and excretion, which plays an important role in understanding the condition, assisting diagnosis and deciding treatment.
Daily intake: including daily drinking water, food water content, liquid input, blood transfusion, etc.
In order to accurately record the intake of oral liquid, a measuring cup or a container with measuring capacity can be used.
Record the unit quantity of solid food, such as two steamed buns, two biscuits, 1 bowl of rice, and record its water content through conversion (see Appendix 3).
Daily output: including feces and urine.
For patients with urinary incontinence, in order to obtain accurate urine volume, urine should be preserved as much as possible. Those who urinate by themselves should record the urine volume every time or concentrate the urine volume in a container, and measure and record it regularly.
Other discharge fluids, such as gastrointestinal decompression extract, vomit, gush, puncture fluid (such as brain and abdominal puncture extract) and drainage fluid (such as bile drainage), should also be measured and recorded as discharge.
Signs recording the amount of in and out should be hung on the bedside, which is convenient for the staff to understand and record in time.