Basic requirements for writing nursing documents:
1, nursing documents and records should be objective, true, accurate, timely and complete, and their full names should be signed. Write in blue ink on the day shift and in red ink on the night shift (see the requirements on each page for details).
2. Medical terms should be used when writing nursing documents, and commonly used foreign language abbreviations and names of symptoms, signs and diseases without formal Chinese translation can be used in foreign languages.
3, nursing documents should be written neatly, legible, accurate expression, fluent statements and correct punctuation. When there are typos in the writing process of nurses on duty, double lines with the same color should be used on the typos, and pens with the same color should be used to correct the underlined typos. Scraping, pasting, smearing and other methods shall not be used to cover or remove the original handwriting, and no more than two places shall be altered on each page. Any numerical error cannot be corrected by the above method.
4, nursing records written in accordance with the provisions, signed by registered nurses; The contents written by trainee nurses and trainee nurses shall be reviewed, revised and signed by the legal trainee nurses of this medical institution; Nurses who have passed the examination by the nursing department and departments can write nursing medical records independently after being reported to the nursing department for the record. Those who fail the examination shall be reviewed, revised and signed by the teaching nurses who are legally practicing in this medical institution.
5, the superior nursing staff has the responsibility to review and modify the nursing records written by the lower nursing staff. When revising, use red pen and double lines, use red pen to revise the crossed-out typos or sentences, and sign the full name and time. The time limit for modification is within 72 hours. Keep the original records clear and easy to read.
6, because of the rescue of critically ill patients, failed to write nursing records in time, should be truthfully fill in the records in time within 6 hours after the rescue, and make records.
7. The time recorded in the document is recorded in 24 hours Beijing time. The units of measurement used are all legal units of measurement in People's Republic of China (PRC).