Nursing record refers to the objective record of nursing process of patients during hospitalization by nurses according to nursing procedures or according to doctor's advice and illness, and it is also the record of patients' treatment process. Complete and accurate nursing records can effectively prove the necessity and legitimacy of nurses' every step of nursing behavior. On September 1 2002, the state promulgated the Regulations on Handling Medical Accidents, which clearly stipulated that nursing records are an integral part of medical records, and patients have the right to copy and copy, and patients and their families should be present during the copying process. Therefore, standardizing the writing of nursing records to prevent nursing accidents is not only convenient for proof, but also related to the favorable evidence of whether nurses are protected by law (complete and reliable nursing records can provide the real process of diagnosis and treatment and nursing services at that time, and record "what to do" according to the actual nursing work procedures, rather than "what to write and do"). In other words, writing a good nursing record sheet is also a very important aspect of our nurses' self-protection.

First, change ideas and raise awareness. With the continuous enhancement of people's legal awareness, people's legal awareness is also constantly improving. Nursing record has become one of the most important bases in medical litigation, which means that every word and symbol in nursing record represents a legal responsibility, and every sentence can be used as a legal basis. At the same time, nursing records are a double-edged sword. On the one hand, standardized nursing records can protect nurses from giving evidence. However, if the work is not in place or the condition changes cannot be found in time, it will delay the treatment or rescue opportunity and cause personal injury to the patient. The same objective nursing record is also the basis of protecting the legitimate rights and interests of patients. Therefore, nurses should not always think that as long as there is practical nursing effect for patients, there is no need to write nursing records that are repeated every day. First, writing nursing records should be raised to the legal level.

Second, the concept: nursing records include: nursing records of ordinary patients and nursing records of critically ill patients. Nursing record sheet of ordinary patients: refers to the objective record of nursing process of ordinary patients during hospitalization by nurses according to doctor's advice and illness. Nursing record sheet of critically ill patients: refers to the objective record of nursing process of critically ill patients during hospitalization by nurses according to doctor's advice and illness. Objectivity: refers to accurately recording the patient's condition without subjective analysis and judgment. Timeliness: it means that problems are recorded in time, and special examinations and special drugs are recorded in time when the condition changes. Integrity: it means that the contents of general nursing records should be complete, including observation of illness, nursing measures and effects.

Third, clear the scope of nursing work. The scope of nursing work is divided into three types according to functions: (1) independent nursing function. Observe the patient's condition, take nursing measures, improve the comfort of patients, carry out health education and observe the effect. Such as: lying position, oral care, perineal care, skin care, etc. (2) Collaborative nursing function. Cooperate with doctors to diagnose and treat patients, with nutritionists to guide patients to drink and eat, and with physiotherapists to guide patients to rehabilitation training. Such as tracheotomy, cardiopulmonary resuscitation and dressing change. (3) Dependence on nursing function. Such as the application of various drugs to patients according to the doctor's advice.

Writing requirements of critical illness record sheet

First, the concept of critically ill patients' nursing records. The records of the nursing process of the crowd nurses according to the doctor's advice and illness during the hospitalization of critically ill patients are called critically ill patients' records. The records of critically ill patients are aimed at the following groups: First, patients in intensive care;

Second, special care patients;

Third, first-class care for critically ill or seriously ill patients. Writing principle of critically ill patients' record sheet: critically ill patients' record sheet should be written according to the nursing characteristics of the corresponding specialty, and the recording time should be specific to minutes. If the rescue is not recorded in time, it must be truthfully recorded within 6 hours, and it shall not be fabricated.

2. The contents and levels of nursing records for critically ill patients include: patient's department, name, sex, age, ward, bed number, diagnosis, hospitalization number, vital signs, treatment, implementation of doctor's orders and drug administration, various pipelines, symptoms, signs, nursing measures and effects, nurse's signature, page number, etc. The writing level of nursing records of critically ill patients should be the same as that of general nursing records.

Third, the writing requirements, content and format of the nursing record sheet for critically ill patients

(1) Writing requirements 1. The contents of the record are true, accurate and complete, and medical terms are used. 2. The handwriting is clear and concise, and there are no typos. 3. Record in time, and do not alter it (double-line the wrong words and sign them when mistakes are found). 4. Numbers should be written in Arabic numerals. 5. Write in chronological order (it should be the actual time of administration, treatment and nursing). 6. The time limit must be completed within 6 hours. The nursing records of critically ill patients should be recorded at any time according to the changes of their condition. If the emergency rescue cannot be recorded in time, it should be completed immediately within this shift or after the patient is treated, and it shall not exceed 6 hours.

(two) the content and format of writing, the content and level of writing should meet the requirements of the specification; The format should be correct, the language should be fluent and the handwriting should be neat; Writing content should be objective and accurate, highlighting nursing content; The treatment, rescue and nursing measures and the items listed in the form should be recorded in detail, and the time and signature should be indicated.

1. Fill in the eyebrow column with blue and black ink pen.

2. Vital sign recording: Record vital signs in detail, with the specific recording time and frequency depending on the patient's condition.

3. Contents of illness record: chief complaints (discomfort and feeling) of patients or their families, changes of illness, clinical manifestations, psychological and behavioral changes observed by nurses, and laboratory reports. According to the corresponding characteristics of specialized nursing, write the treatment plan, nursing measures and nursing effect. Surgical patients should focus on recording: anesthesia mode, operation name, patient's return to ward, wound condition, drainage condition, etc. The rescue record should describe the process of illness change in detail, accurately record the rescue process, time and stop time, which should be consistent with the medical records. If the record cannot be completed in time, it shall be completed within six hours after the rescue.

(3) Frequency of recording First of all, it should be recorded at any time according to the change of illness; Secondly, it should be recorded according to the time limit required by the doctor's advice. For example, if the doctor's advice requires blood pressure to be measured every 2 hours, the nurse should record a critical record every 2 hours according to the doctor's advice; If the patient's condition is stable, the recording interval can be appropriately extended. It is not necessary to record every 15 ~ 30 minutes, but the interval should not be too long. You should still visit the patient once every 15 ~ 30 minutes, or stay with the patient for intensive care all the time, but the writing interval can be appropriately extended when the condition is stable.

(4) The quality standard and quality control of nursing records of critically ill patients should be legible and neat, and medical terms should be used. Secondly, records should be timely, accurate, objective and specific. Language description, data recording, etc. It should be very accurate, and it should be the objective existence of the patient, not the subjective judgment or reasoning conclusion of the nurse. Third, it can reflect the change and treatment of the disease. We can record the patient's condition changes in time after observation, and take effective nursing measures and medical measures in time for the patient's condition changes and problems, which should also be recorded in time.