In order to effectively reduce the burden of nurses in writing nursing documents, strengthen basic nursing, implement the nursing handover system, and ensure the safety of patients, the relevant requirements and format specifications are as follows:

1. Nursing documents should be written in table format according to the Basic Specification for Medical Record Writing issued by the Ministry of Health.

2. Nursing documents should be written and signed by practical nurse registered in this medical institution. Unregistered nurses and intern students can't sign their names separately, but they should be reviewed, revised and signed by nurses who are legally practicing in this medical institution, and signed in the following ways: teacher (registered nurse)/student's name.

3. Nursing documents include: temperature list, doctor's advice list, operation counting record list and nursing record list of critically ill patients, all of which can be recorded in tabular format.

3. Nursing documents include: temperature list, doctor's advice list, operation counting record list and nursing record list of critically ill patients, all of which can be recorded in tabular format.

(1) temperature list: lintel column and column are written completely, and there is no omission.

(2) Medical orders: Nurses should execute them in time and accurately, and make sure that those who execute them are signed with clear handwriting.

(3) Operation inventory record sheet: It should be completed in time after the operation, and signed by the surgeon, equipment nurse and visiting nurse.

(4) nursing record sheet for critically ill patients: the content should be objective, true, accurate, timely and standardized; Use medical terminology with neat writing, clear handwriting and correct punctuation.

4. The date and time of medical records shall be written in Arabic numerals, with 24-hour recording.

5. The contents of the nursing documents are objective, true, accurate, timely and complete, reflecting the patient's condition dynamics and the continuity of nursing, including the observation of the patient's condition, the implementation and effect of TCM dialectical nursing measures, health education and emotional nursing.

6. If the emergency treatment fails to be recorded in time, the nurse on duty shall make up the record according to the facts within 6 hours after the rescue, and indicate the completion time of the rescue and the time of making up the record.

7. The items and dates of nursing documents should be filled in completely, the layout should be neat, the writing should be clear, the handwriting should be neat, and the expression should be accurate, without scraping, smearing and pasting.

8. In order to organically combine the contents of nursing writing with the medical records, unify each other, and avoid duplication and contradiction, the nurses in charge should communicate with the competent doctors more, so as to keep the disease records and some objective data in the nursing records consistent with the medical records, especially to reflect the changes of the disease.

Significance of nursing document record:

1. The basis of diagnosis, treatment and nursing is the original record file of medical staff in clinical junior middle school, and the complete medical record is an important basis for diagnosis, treatment and nursing. When a patient is in a critical situation or hospitalized again, it is necessary to make a comprehensive judgment and analysis based on the previous medical record data in order to make a correct treatment.

3. The writing and recording of important information and reference medical records of hospital management assessment can reflect the service quality and technical level of the hospital, which is not only important information of hospital management, but also reference materials for assessing medical staff.

4. The original medical records of medical statistics are the original records of medical statistics, which can provide prevention and treatment and epidemiological investigation.

Reference: Nursing Documents-Baidu Encyclopedia