1. The nursing system in clinical departments is 1. The temperature, pulse and respiration of newly admitted patients were measured twice a day for 3 days (8 am and 4 pm). If there is no abnormality, take temperature, pulse and respiration 1 time at 4 pm every day; If the body temperature reaches 37.5℃ or above, measure the body temperature and pulse breathing three times a day (8: 00 am, 4: 00 pm and 8: 00 pm); For patients undergoing major surgery and those with a temperature above 38.5℃, the temperature, pulse and respiration 1 time were measured every 4 hours, and it was changed to 1 time every day after the temperature returned to normal for 3 days. The blood pressure and weight of newly admitted patients should be measured once (blood pressure is exempted for children under seven years old as appropriate), and patients who can get up and stand should be weighed once a week. Others should be carried out according to routine and doctor's advice. The average patient has to urinate once a day. 2. After the patients are admitted to the hospital, they should be marked on the patient list and bedside board according to the nursing classification (the first-level care is red, the second-level care is * *, and the third-level care is not marked), and the list of critically ill patients should be marked with red "?" Express delivery. 3, according to the patient's condition and needs, earnestly implement the grading nursing system. 4, do a good job in basic nursing, and according to different diseases, earnestly implement the specialized disease care routine. 5, strict nursing technical operation procedures and disinfection and isolation system, to ensure the medical safety of patients. 2. The duty shift system is 1, and each shift shifts on time. The successor arrives at the department 10- 15 minutes in advance to read the shift log book and temperature log book. The successor shall not leave his post before taking over. 2. The personnel on duty must finish all the work of the class before the shift, write the shift report and record form of all documents, and handle the used items. In case of special circumstances, the shift must be changed in detail. 3, day shift to prepare for the night shift, such as disinfection dressing, test tube, syringe, clothes, common equipment, etc., so that the night shift can work smoothly. 4. If you are not clear about the illness, treatment, equipment and articles during the shift change, you should ask immediately. Successors should be responsible for the problems found in the process of succession, and successors should be responsible for the problems found after succession. 5. The day shift shift report is written by the nurse in charge of the shift, which requires prominent points and concisely explains the condition, diagnosis and treatment of critically ill patients and newly admitted patients. If a senior nurse or nursing student writes a shift report, the teaching nurse or head nurse is responsible for revising and signing it. 6, before the succession, the head nurse should check the implementation of the doctor's advice and records of critically ill patients, after the morning meeting, night shift nurses will focus on patrolling critically ill patients and new patients, and arrange nursing work. 7, each class should be serious, must be three clean (hand-over records to write clearly, oral account to make it clear, the patient's bedside to see clearly). 8. Handover contents (1) The total number of hospitalized patients, the number of discharged patients, the number of transferred professionals, the number of transferred hospitals, the number of deliveries, the number of operations, the number of deaths, and the changes of new patients, critically ill patients and patients undergoing special examination and treatment before and after the operation. At the same time, we should pay attention to patients with mood swings and anxiety. (2) Make clear the implementation of doctor's orders, intensive care records, collection of key specimens and completion of all kinds of disposal, and make clear the unfinished work to successors. (3) Check whether coma and paralysis patients have bedsores and the completion of basic nursing. (4) Check the patient's wound, the fixation and drainage of various catheters and the patient's infusion. (5) Counting items, paying attention to standing posture, first aid, handover and succession of precious medicines, articles and equipment, and registering. (6) The nurses on duty should stick to their posts and not change shifts without authorization. 3. Check the system (a), the doctor's advice check system 1, after the doctor's advice is executed, BANCHA should be in the class, and both of them should sign it after checking it. 2, temporary doctor's advice to record the execution time and sign the full name, the doctor's advice in question must be asked before execution. 3. When rescuing a patient, the doctor gives a verbal order, and the executor must repeat it. It can only be carried out after the doctor confirms that it is correct, and the used empty ampoules are kept, and then discarded after inspection. After rescuing the patient, the doctor must be urged to fill in the doctor's advice. 4, often check the doctor's advice twice a week, the head nurse to attend at least once, and make records. 5, a single person on duty should carry out the doctor's advice on the next BANCHA. (2) Check the medication and injection system 1. Before taking medicine and injecting, we must strictly implement the "three checks and eight checks", that is, check the bed number, name, dosage, concentration, time, drug name, usage and expiration date before, during and after operation. 2, dispensing and dispensing, should pay attention to check the quality of drugs, pay attention to the moisture, tablets with and without deterioration, deliquescence, injection with and without cracks, pay attention to the validity period and batch number, such as does not meet the requirements or label is not clear shall not be used. 3. After dispensing, it must be checked by a second person before execution. When dispensing medicine, the patient must take the medicine before leaving. 4. Before using allergic drugs, you should ask whether this kind of drugs has allergic history. Before using them, you should do allergic tests. When using toxic, hemp and drama-limited drugs, you should go through repeated inspections and keep ampoules. When using several drugs, we should pay attention to whether there are compatibility taboos. 5, medication, injection, if the patient or others ask questions should be checked in time, after verification. 6, sorting injection list, medication list, treatment list must be checked by two people before use, the original list should be saved until the next doctor's advice. 7, medication, injection, all need to take a medication list, injection list. 8, get medicine, must check the bed number and name before injection, and correct the rear can perform. (3), infusion inspection system 1, strictly implement the "three checks and eight pairs" system. 2, carefully check the infusion card, after adding liquid medicine must be signed, indicate the time. 3. Before dispensing, check whether the aluminum cover on the mouth of the infusion bottle is loose, whether the bottle body is cracked and whether the liquid medicine is deteriorated. Pay attention to the batch number and expiration date at the same time. Do not meet the requirements or the logo is unclear, and shall not be used. 4, when using a variety of drugs should pay attention to whether there are any compatibility taboos, check whether there are small particles, turbidity, discoloration, etc. Mix and put in a medicine bottle. 5, easy to cause allergic drugs, before using this kind of drugs should be asked whether there is a history of allergy, query drug allergy test records. 6, infusion, such as patients or others ask questions, should be checked in time, after verification can continue to perform. (4), blood transfusion examination system 1, before collecting blood samples, the patient's name, bed number and ward must be accurately filled in, and the joint number on the test sheet should be posted on the test tube. 2. When taking blood, the test tube must be taken to the patient together with the blood transfusion application form, and blood can be taken only after checking the bed number, name and specimen serial number. 3, at the same time, there are more than two patients need to match blood, must be carried out separately, to avoid more than two blood matching test tubes to match blood to patients at the same time, in case of mistakes. 4. Blood samples must be sent by doctors or nurses, not by patients or their families. 5. After the blood is retrieved, the two must * * check the patient's name, bed number, hospitalization number, blood type, blood donor's name, blood type and blood volume on the blood matching report, and check the cross-examination results. After confirmation, two people can sign before execution. 6, pay attention to the presence of blood clots, blood bags with and without cracks. 7, check the bed number and name again before blood transfusion. 8. When starting blood transfusion, slow down and observe at the bedside for ten minutes before leaving. In the whole process of blood transfusion, we must closely observe the blood transfusion reaction. If there is any reaction, stop blood transfusion immediately, and notify the laboratory to recheck the matching while doing the corresponding treatment. 9. After blood transfusion, the blood bag should be kept for 24 hours, and the blood transfusion response card should be filled in and kept in the medical record. (5), the operating room check system 1, pick up the patient, check the patient, bed number, name, sex, diagnosis, operation name, preoperative medication. 2, before the operation, must check the name, diagnosis, operation name, location, anesthesia method and anesthetic drugs. 3, check the validity of aseptic packaging, sterilization instructions. 4, where the body cavity or deep tissue surgery, before the operation to count all the dressings and instruments and suture. 5. Specimens taken after operation should be checked by the hand-washing nurse and the operator, and then the pathological checklist should be filled in for inspection. (6), supply room inspection system 1, check the name, quantity, quality and cleanliness when preparing the table. 2. Please check the name and expiration date when sending the set. 3. When taking back the equipment, check the quantity, quality and cleaning. 4. Check the temperature, pressure and time during sterilization, check the sterilization effect index after sterilization, and check whether there is a wet package. It can only be used after it meets the requirements. 4. Implementing the system of doctor's advice is a medical instruction issued by a doctor in medical activities. The writing of doctor's orders shall conform to the provisions of Article 29 of the Basic Specification for Medical Record Writing (Trial) formulated by the Ministry of Health and state administration of traditional chinese medicine. 1, the execution of the doctor's advice should be accurate and completed within the effective time. The medical order execution record shall be objective, true and original, and the executor shall sign the full name and execution time. The doctor's advice must be checked and signed by two people. 2, under normal circumstances, the nurse shall not perform oral orders, doctors need to give oral orders to emergency patients, nurses need to repeat, after repeated; After the rescue, please ask the doctor to make up the facts in time. If the nurse fails to sign the record in time because of rescuing the patient, she should make up the record according to the facts within 6 hours after the rescue. 3, all the doctors' orders that need the overall cooperation of nurses, such as routine care, level care, diet care, local treatment, etc. , can be signed by the main nurse or the nurse on duty on the long-term doctor's advice. 4. After the long-term doctor's advice is executed, the executor shall sign the execution time on the long-term doctor's advice execution list. After the execution of temporary medical orders, the executor shall directly sign the corresponding column of temporary medical orders. 5, after surgery, after delivery, stop the preoperative and prenatal doctor's advice. 6. Who needs to clear the next order? 7. Interns have no right to issue doctor's orders separately, and they need to be signed by the superior doctor after issuing the doctor's orders, which will be effective after verification. 8, strictly implement the doctor's advice check system. 9, discharge, transfer, specialist, death patients should cancel all kinds of execution list in time. V. Writing system of nursing documents (1) Writing principles 1. Follow the requirements of the Basic Specification for Medical Records Writing (Trial) issued by the Ministry of Health and state administration of traditional chinese medicine and the Regulations on Medical Records Management in Medical Institutions. Nursing documents should be objective, true, accurate, timely and complete. 2. According to the quality standards and implementation requirements of graded nursing in Anhui Province, nurses carry out graded nursing for inpatients and implement various nursing measures according to the nursing level. 3, nursing documents should be written in blue and black ink, the recorder must sign the full name. Nursing documents written by trainee nurses should be immediately reviewed by the legal trainee nurses designated by this medical institution, and their revision opinions, revision dates and signatures should be written in red ink. 4, nursing documents should be neat words, clear charts, neat handwriting, accurate and fluent statements, symbols, punctuation correctly. When there is a typo in the writing process, you should draw it with double lines and correct it. Scraping, gluing and painting are not allowed to cover or remove the original handwriting. 5. The same items in the lintel of all kinds of nursing documents are: patient's name, department, ward, bed number, hospitalization number or medical record number. 6. Medical institutions can still design documents such as "blood pressure measurement record" and "24-hour liquid volume record" according to the doctor's advice and the patient's situation, and their writing should follow this principle and be included in the medical record management if necessary. 7. Nursing records such as nursing rounds, teaching rounds, discussion of difficult cases and case analysis are opinions, comments and suggestions put forward by nursing staff through observation, analysis and discussion of patients' condition, which belong to subjective nursing documents and are not included in medical record management for the time being, nor provided to patients (or their legal representatives). 8. Before filing nursing documents, medical institutions should designate special personnel to evaluate them according to the Quality Evaluation Standard of Nursing Documents formulated by Anhui Province, and the nursing documents can only be filed after evaluation. 9. All records must have a complete date. 10. At the end of each handover record, the full name must be signed. 1 1. All records and documents shall be properly kept. (II) Nursing records of inpatients According to the quality and implementation requirements of graded nursing in Anhui Province, general patients refer to the applicable objects of "special care" and "first-class care" prescribed by doctors except critical and severe patients. Its writing must follow the basic principles of nursing document writing and the following requirements: 1, and hospitalization nursing records include "hospitalization nursing records" (home page) and "hospitalization nursing records" (continued page). 2. The inpatient care record (home page) refers to the record written by the responsible nurse or the nurse on duty after the patient is admitted to the hospital, which should be completed in the class. 3. The "admission diagnosis" on the inpatient care record (home page) refers to the diagnosis written by the doctor on the "admission record". "Drug allergy history", if it is "Yes", the specific drug name should be clearly written, such as penicillin. "Skin condition", if it is "abnormal", should specify the specific conditions of abnormality, such as abrasion or pressure sore, its location, scope and degree. 4, in-hospital nursing records (home page) on the "specialist", should record the main symptoms and positive signs of patients with specialized diseases. "Nursing measures" are measures to maintain patients' physical, psychological and social health according to their condition observation and doctors' suggestions. 5. After the first recording is completed, start a new line, which is signed by the recorder (signature position: right alignment) and record the time of the next signed line. The unfinished part of the home page can continue to be used. If there are empty items in the content, draw "/"(cross out). 6. The nursing record of inpatients (continued page) is an objective record of the nursing process of ordinary patients during hospitalization. The contents include recording date, time, observation of illness, treatment measures and effects, and nurse's signature. 7. The observation of the condition requires recording the objective dynamic changes of the patient's condition and drug reactions, such as chief complaint, vital signs, skin, diet, excretion and other abnormalities. Disposal measures and effects, it is required to record the implemented nursing measures related to the condition, as well as the patient's response and results after disposal. 8, nursing records should be recorded at any time according to the patient's condition changes. Special examination, treatment, medication and operation should be recorded immediately. Patients undergoing major surgery should observe and record at any time, and record at least 1 time per shift until 72 hours. Under normal circumstances, surgical patients should record at least/kloc-0 per shift within 24 hours. When the patient's condition is stable, the recording frequency is determined according to the nursing level. First-level nursing patients record 1~2 days, second-level nursing patients record 1 times every 3 days, and third-level nursing patients record 1 times every week. 9. When the patient is discharged from the hospital, a discharge nursing record should be written, which should be completed within 24 hours after the patient is discharged from the hospital. The contents include discharge date, nursing summary, health guidance and nurse's signature. 10, when the patient's condition turns critical, etc. , the record should be transferred. If the doctor's order is "critical", the "nursing record of critical patients" should be transferred out, and the reasons for the transfer should be indicated on the original record sheet. The page number of the transferred record must be extended with the page number of the original record. 1 1. Writing format of inpatient nursing records (continued page): First, record the writing date and time (left-aligned), and write the record on a new line with two spaces in the middle. After recording, write the record signature on a new line (right-aligned). If there are no special circumstances, the page number of in-patient nursing records (continued pages) will be compiled from 1 page. (3). Nursing records of critically ill patients 1. Nursing record of critically ill patients refers to the objective record of nursing process of critically ill patients during hospitalization according to doctor's advice and illness. Anyone who writes nursing records of critically ill patients can no longer write "nursing records of hospitalized patients". 2. According to the Quality Standard and Implementation Requirements of Graded Nursing in Anhui Province (Trial) (Wei Yi, Anhui [20065438+0] No.49), the nursing records of critically ill patients are suitable for patients who are critically ill and need to be observed or monitored at any time for rescue. Such as severe trauma, massive hemorrhage, various complicated and difficult major operations, organ transplantation, extensive burns, multiple organ failure, shock, coma, premature infants, etc. Are critically ill patients in intensive care and first-class care. 3. Recording requirements: record at any time according to the change of illness, the recording time should be specific to minutes, and the nurse will sign it after recording. When the situation is stable, record at least 1 time per shift. 4. Record content: Record the temperature, pulse, respiration, blood pressure, consciousness, pupils and so on in detail. The record of consciousness and pupil should be filled in accurately according to the reference picture, and the reflection of pupil on light should be recorded in the column of "current observation" 5. Record the contents and requirements of intake and output: (1) Intake includes daily drinking water, moisture in food, enteral nutrition, transfusion volume, etc. In order to accurately record the oral liquid intake, a measurable container should be used for measurement. The quantity of solid food should be recorded, and then the water content should be converted into records. Output refers to the patient's defecation, vomiting, expectoration, gastrointestinal decompression, peritoneal lavage and various drainage. Patients with urinary incontinence should try to keep the amount of catheterization records; For those who urinate by themselves, record the urine volume each time, or measure and record the urine volume for 24 hours in a container according to the needs of the disease. (2) Inflow and outflow statistics: subtotal and total are needed once a day. Before going to work in the day shift, write down the amount of in-and-out (draw a blue horizontal line to summarize the amount of in-and-out for one day), and in the night shift, summarize the amount of in-and-out for 24 hours at 7: 00 the next morning (draw a blue horizontal line with blue pen drawing, and then draw a blue horizontal line), and transfer it to the temperature list at the same time. 6. Observation and treatment of illness: including the patient's illness change, drug reaction, skin, diet, sleep, excretion and other abnormal conditions, the measures taken for abnormal conditions, the patient's reaction and results after treatment. Six. Graded nursing system After a new patient is admitted to the hospital, the nursing grade should be determined according to the severity of the illness and marked. Graded nursing is often divided into the following four grades: (1) special nursing 1. Applicable object: patients who are in critical condition and need to be observed or monitored at any time for rescue. Such as severe trauma, massive hemorrhage, various complicated and difficult major operations, organ transplantation, extensive burns and multiple organ failure. 2. Quality standard: (1) Set up a 24-hour special person for nursing or set up a special ambulance team for nursing. (2) Using nursing procedures, formulate and implement nursing plans to meet patients' physical and mental nursing needs. Make necessary nursing records. (3) Closely observe the condition and master the reaction and effect after medication. Strictly implement various diagnosis and treatment nursing measures, accurately control the speed of infusion (blood transfusion), and actively cooperate with doctors for rescue and disposal. Fill in the special nursing record form timely and accurately. (4) Do a good job in basic nursing and establish a turn-over card according to the illness. Preventing nursing complications and ensuring patient safety. (5) Send water, rice, medicine and toilet to the bedside. (6) Prepare emergency medicines and equipment to meet the needs of emergency rescue. (ii) Primary health care 1. Applicable object: critically ill patients who need strict bed rest. Such as major surgery, shock, paralysis, coma, high fever, bleeding, liver and kidney failure and premature infants. 2. Quality standard: (1) Closely observe the patient's condition change, master the patient's reaction and effect after taking the medicine, and patrol the patient every 30 minutes. (2) Formulate and implement the nursing plan for critically ill patients, and try to meet the nursing needs of patients in both physical and psychological aspects. Make necessary nursing records. (3) Strictly implement various diagnosis and nursing measures, accurately control the speed of infusion (blood transfusion), establish an infusion patrol card, and actively cooperate with doctors for first aid. (4) Do a good job in basic nursing and establish a turn-over card according to the illness. Preventing nursing complications and ensuring patient safety. (5) Send water, rice, medicine and toilet to the bedside. (6) Prepare emergency medicines and equipment to meet the needs of emergency rescue. (3) secondary care 1. Applicable objects: patients with serious diseases and decreased self-care ability, such as those whose condition tends to be stable after major surgery, the elderly, the infirm, children and patients with chronic diseases. 2. Quality standard: (1) Carefully observe the change of illness, and master the reaction and effect of patients after taking the medicine, and patrol once every 1-2 hours. (2) Strictly implement various diagnosis and treatment and nursing measures, and give drugs accurately. Establish an infusion patrol card according to the needs of the illness. (3) Carefully do basic nursing to prevent nursing complications and ensure the safety of patients. (4) Send water, rice and medicine to the bedside. (5) according to the condition need to prepare rescue drugs and equipment. (6) Give health guidance, and try to meet the patients' physiological and psychological nursing needs. (4) tertiary care 1. Applicable objects: mild patients, who can basically take care of themselves, such as general chronic patients, convalescent patients, preoperative preparation patients, etc. 2. Quality standard: (1) Carefully observe the change of illness, master the reaction and effect of patients after taking medicine, and patrol the ward at least twice a day. (2) Strictly implement various diagnosis and treatment and nursing measures, and give drugs accurately. Establish an infusion patrol card according to the needs of the illness. (3) Carefully do basic nursing to prevent nursing complications and ensure the safety of patients. (4) Send water, rice and medicine to the bedside. (5) Give health guidance and try to meet the patients' physical and mental care needs. Urge patients to abide by hospital regulations. Seven. Health education system 1. Nurses should give health education to each hospitalized patient. 2. Health education should run through the nursing process. 3. Carry out patient education in strict accordance with health education procedures. 4. According to the classification of health education, outpatient education, inpatient education, discharge education and community education were given respectively. 5, master the skills of health education, appropriate use, including nurse-patient relationship skills, nurse-patient communication skills, behavior training skills.