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1、Nursing Documentation,Nursing Documentation,purpose of records,communicatingProviding theoretical basis for planning client treatment and careProviding data for education and researchProviding basis for quality reviewProviding basis for legal purpose,purpose of recordscommunicat,principle of record,
2、1、recording procedures in time2、accuracy3、completeness4、objectivity5、well-organized presentation,principle of record1、recordi,医疗与护理文件的管理,管理要求各种护理文件按规定放置，记录和使用后必须放回必须保持医疗护理文件的清洁、整齐、完整、防止污染、破损、拆散、丢失患者和家属不得随意翻阅医疗护理文件的记录资料，不得擅自将医疗护理文件带出病区医疗文件应妥善保存：出院或死亡的病案应整理后交病案室，并按卫生行政部门规定的保存期限保管。体温单、医嘱单、特别护理记录单长期保存。病
3、区交班报告本保存1年，以备查阅。发生医疗事故纠纷时，应在医患双方同时在场的情况下封存，并由医疗机构负责医疗服务质量监控的部门或专职人员保管。,医疗与护理文件的管理管理要求,放置位置,病历夹,病历车,病案室,放置位置病病病案室,管理要求,order of admission record1、temperature sheet2、physicians order sheet3、admission record4、The history and physical examination5、physicians record6、consultation record7、diagnostic studi
4、es reports8、nurses record9、standing order execute sheet10、first page of client record11、outpatient record,order of discharge (transfer ,death) record)1、first page of client record2、discharge or death record3、admission record4、The history and physical examination5、physicians record6、consultation reco
5、rd7、 diagnostic studies reports 8、nurses record9、 physicians order sheet 10、 standing order execute sheet11、temperature sheet12、outpatient record is given back to the client or the clients family,管理要求order of admission reco,护理文书书写课件,护理文书书写课件,writing nursing documents,1、temperature sheet2、managing ph
6、ysicians order3、recording fluid intake and output4、recording special nursing5、reporting clients conditions6、nursing history,writing nursing documents1、tem,1、temperature sheet,The temperature sheet is used to record the temperature, pulse, respiration, blood pressure, body weight, fluid intake and ou
7、tput, urine, bowel movements, and admission time, discharge time, operation time and so on.The temperature sheet is on the first page of clients hospitalization record.,1、temperature sheetThe tempera,This part must be filled in with a blue-inked or carbon inked pen.Clients name, age, ward, bed numbe
8、r, admission date and time, and hospitalization number must be filled in legibly and completely.When writing “date”, year, month and day must be filled in the first day column of every page. As for the rest six days column only “day” is to be filled. Year, month, and day or month and day must be fil
9、led in if a new month or a new year starts within the six days.,Filling in top part,This part must be filled in wi,4、Days of hospitalization are written in Arabic number “1,2,3”from the day of admission to the day of discharge.5、The next day of operation (childbirth) is regard as the first day of op
10、eration (childbirth) that has been charted continuously on the day column of temperature sheet in Arabic number “1,2,3” until 14 days. If second operation has been done within 14 days, then stop writing the number of days of the first operation, filling in -0 on the day column of the second operatio
11、n in Arabic number until the 14days.,Filling in top part,4、Days of hospitalization are,眉栏,济宁医学院附属,张三,心内科,5床,2010-12-29,687536,2010-12-29,30,31,2011-01-01,2,3,2,3,4,5,6,7,1,2,3(2),4,1,1/4,体温记录单,眉栏济宁医学院附属张三心内科5床2010-12,Filling in between 40 -42 column of temperature sheet,This part is filled in with a
12、 blue-black inked or carbon inked pen.Time of admission, operation, childbirth, transfer, discharge or death is filled in the vertical line of corresponding time column between 40 -42 column of temperature sheet. When recording the time of admission and death, it is essential to specify the minute,F
13、illing in between 40 -42 c,Filling in between 40 -42 column of temperature sheet,Method and location: the nurse should write in longitudinal line: “admission- nine thirty,” operation- ten oclock. If the time of operation or other items is not equal to the time at temperature sheet, fill in the proxi
14、mal time column. For example, if admission is at 11 oclock, then fill within “10” oclock column. If operation is on 1 oclock in the afternoon, then fill within “2” oclock column.,Filling in between 40 -42 c,4042横线之间,入院-八时二十分,分娩于二十时十三分,转出-九时二十分,出院-十五时三十分,4042横线之间入院-八时二十分分娩于二十时十三分转出,Drawing body tempe
15、rature curve and sphygmogram,Oral temperature is represented by blue “ ” ,Axillary temperature is represented by blue “ X”, Rectal temperature is represented by blue “ ”. Two adjacent readings are connected by blue line. If there is any reason that a clients body temperature has not been measured,A
16、client with hyperpyrexia needs to have his or her body temperature taken again in half an hour after receiving physical therapy for lowering body temperature.For clients who need close observation of body temperature,If a clients body temperature is below 35 ,drawing body temperature curve,go,Drawin
17、g body temperature curve,体温的绘制,T曲线绘制,v,不升,体温的绘制T曲线绘制v不升,Drawing sphygmogram,Pulse rate is drawn in red “ ”, and heart rate is in red “ ”. Two corresponding readings of pulse rate or heart rate are connected by red line.If the reading of body temperature and pulse rate are at the same point,x,Drawing
18、 sphygmogramPulse rate,脉搏的绘制,P、心率曲线绘制,脉搏短绌,脉搏的绘制P、心率曲线绘制脉搏短绌,Respiration,Readings of respiration are recorded in corresponding time columns.It is filled in by using a blue-black inked or carbon inked pen.,18,18,19,20,22,19,18,18,Respiration Readings of respir,体温单34以下各栏目，用蓝黑、碳素墨水笔填写。,体温单34以下各栏目，用蓝黑、碳
19、素墨水笔填写。,Filling in bottom part,Blood pressureBody weightBowel movementIntravenous infusion fluid and urinePage number,Filling in bottom partBlood pr,底栏,底栏,2.Managing physicians order,The physicians order is usually a written order prescribed by the physician in the process of treatment.Contents of p
20、hysicians order：Date, time, routine care. Grade of nursing, diet. Body position, medication (name, dosage), routes of administration, physicians signature, and nurses signature.,2.Managing physicians order T,医嘱范例：,呼吸内科护理常规一级护理低脂饮食吸氧 prn 5%葡萄糖 250ml氨茶碱 500mg速尿20mg iv st 舒乐安定 5mg. po.sos明晨禁食行B超检查,2013
21、-10-19 9:00am,张平,ivgtt.qd,医嘱范例：呼吸内科护理常规2013-10-19 9:00am,standing order：a standing order is valid until it is cancelled by the physician or the prescribed number of days elapses. usually the valid time of a standing order exceeds 24 hours.,Types of physicians order,一级护理心内科护理常规低盐饮食消心痛10mg po tid,一级护理
22、半流质饮食10%葡萄糖250ml+氨苄西林3.0g ivgtt qd,standing order：a standing ord,stat order：a STAT order signifies that a single dose of medication is to be given immediately, usually only once. The valid time limit of a STAT order is within 24 hours.,需立即执行，阿托品0.5mg H. st .需在限定时间内执行，会诊、手术、血、尿、粪常规检查，X线摄片及各项特殊检查等出院、转
23、科、死亡也属于临时医嘱需一日内连续用药数次者，按临时医嘱处理。如奎尼丁0.2g po q2h5,Types of physicians order,stat order：a STAT order signi,Types of physicians order,备用医嘱： (1) PRN order：PRN order is a kind of standing order. The physician may order a drug on a PRN basis if the clients condition needs. Often the physician sets minimal
24、intervals between two times of administration. This means that a drug cannot be given more frequently than what is prescribed. An example of PRN order is Dolantin(杜冷丁) 50mg IM q6h prn.,Types of physicians order备用医嘱,Types of physicians order,备用医嘱： (2) sos order: the valid time of the SOS order is wit
25、hin 12 hours. It will be carried out only once as the state of an illness needs. It becomes invalid if it exceeds the time limit, for example, Dolantin 50mg IM SOS.,Types of physicians order备用医嘱,护士签名,李丽,刘凤,维生素B110mg po tid,、,维生素E0.1g po tid,、,测BP、pq6h,刘凤,9:00,05-04,、,青霉素80万u imbid,、,半流质饮食,、,二级护理,内科常
26、规护理,9:00,2010-05-02,医师签名,时间,日期,时间,日期,停 止,护士签名,医师签名,医嘱内容,开 始,长期医嘱单,姓名 陈敏 病区 内科 床号 5床 住院号20100578,刘凤,护士签名李丽刘凤维生素B110mg po tid、维生素E,临时医嘱单,姓名 陈敏 病区 内科 床号 5床 住院号20100578,时 间,日 期,刘凤,X线胸片,、,心电图,、,小便常规,、,大便常规,、,血常规,、,明晨抽血测k,、,安定10mg im sos,、,阿托品0.5mg im st,青霉素皮试（ ）,9:00,2010-05-02,执行者签名,执行时间,医师签名,医 嘱 内 容,开
27、始,刘凤,临时医嘱单姓名 陈敏 病区 内科,长期医嘱处理护士将长期医嘱单上的医嘱分别转抄至各种执行卡上，转抄时须注明执行的具体时间并签全名。护士执行长期医嘱后应在长期医嘱执行单上注明执行的时间，并签全名。,Managing physicians order,长期医嘱处理Managing physicians ord,护士签名,刘凤,维生素B110mg po tid,、,维生素E0.1g po tid,、,测BP、pq6h,李丽,、,青霉素80万im bid,、,半流质饮食,、,二级护理,刘凤,内科常规护理,9:00,2010-05-02,医师签名,时间,日期,时间,日期,停 止,护士签名,医师
28、签名,医嘱内容,开 始,长期医嘱单,姓名 陈敏 病区 内科 床号 5床 住院号20100578,护士将长期医嘱栏内的医嘱分别转抄至各种执行单上(如服药单、注射单、输液单、饮食单等),转抄后在医嘱单上签全名,护士签名刘凤维生素B110mg po tid、维生素E0.,临时医嘱处理需立即执行的医嘱，护士执行后，必须注明执行时间并签上全名。有限定执行时间的临时医嘱，护士应及时转抄至临时治疗本或交班记录本上。会诊、手术、检查等各种申请单应及时送到相应科室。,Managing physicians order,临时医嘱处理Managing physicians ord,临时医嘱单,姓名 陈敏 病区 内科
29、 床号 5床 住院号20100578,时 间,日 期,刘凤,X线胸片,、,心电图,、,小便常规,、,大便常规,、,血常规,、,明晨抽血测k,、,安定10mg im sos,王兰,、,阿托品0.5mg im st,9:30,刘凤,青霉素皮试（ ）,9:00,2010-05-02,执行者签名,执行时间,医师签名,医 嘱 内 容,开 始,写在临时医嘱栏内，护士在执行后，必须写上执行时间并签全名。,临时医嘱单姓名 陈敏 病区 内科,备用医嘱处理长期备用医嘱：由医生开写在长期医嘱单上，必须注明执行时间。如哌替啶50mg im q6h prn。护士每次执行后，在临时医嘱单内记录执行时间并签全名，以供下一班
30、参考。临时备用医嘱：由医生开写在临时医嘱单上，12h内有效。地西泮5mg po sos ,若过时未执行，则由护士用红笔在该项医嘱栏内写“未用”二字。,Managing physicians order,备用医嘱处理Managing physicians ord,停止医嘱处理把相应执行单上的有关项目注销，同时注明停止日期和时间在医嘱单原医嘱后，填写停止日期、时间，最后在执行者栏内签全名,Managing physicians order,停止医嘱处理Managing physicians ord,Managing physicians order,重整医嘱处理：凡长期医嘱单超过3张，或医嘱调整项
31、目较多时需重整医嘱。由医生在原医嘱最后一行下面划一红横线，在红线下用红笔写“重整医嘱”（ “术后医嘱”、“分娩医嘱”、“转入医嘱”等），再将红线以上有效的长期医嘱，按原日期、时间的排列顺序抄于红线下。抄录完毕核对无误后签上全名。医生重整医嘱后，由当班护士核对无误后在整理之后的有效医嘱执行者栏内签上全名。,Managing physicians order重整医嘱,Executing before transcribingUrgent before routineSTAT Order before STANDING Order One order only includes one subjec
32、t, noting time in minute manner. The nurse has responsibility for checking its correctness.The order could not be changed. If it is to be canceled, note “cancel” with a red pen and sign.Generally speaking, the physician should not give oral orders. If a STAT or SOS order is to be carried out on the
33、next shift, the order should be written down in the nursing notes.,Principles of managing,Principles of managing,After transcription or rearrangement, the orders have to be checked by two nurses with their signatures. The physicians orders must be checked in every shift and totally once every week.P
34、erson who carries out the physicians order has to sign his or her full name in the treatment sheet and physicians order sheet.,Principles of managing,Principles of managing,3.Recording fluid intake and output,A healthy adult can usually maintain normal intake and output fluid balance. Imbalances may
35、 occur if a client has cardiovascular disease, renal disease, severe burns, hemorrhage, or extensive surgery.,3.Recording fluid intake and o,Recording fluid intake and output,fluid intakeFluid intake includes daily oral fluid intake, food intake, and intravenous fluid infusions etc.,fluid outputThe
36、major fluid output is urinary output. Other output fluids include amount of stool, vomit, bleeding, sputum, gastric suction, and drainage from post-surgical drainage tubes.,Recording fluid intake and out,Recording fluid intake and output,Methods for recordingThe heading must be documented with blue-
37、black inked or carbon inked pen.Amounts of fluid intake and output are usually recorded in ml.Intake and output at the same time are recorded on the same transverse line, and those at different times are recorded on respective lines.,Recording fluid intake and out,Recording fluid intake and output,M
38、ethods for recordingDaytimes fluid intake and output are recorded with a blue-black inked or carbon inked pen, nighttimes fluid intake and output are recorded with a red pen.Various types of intake and output are summarized at the end of each 12-hour and 24-hour period. Sum of intake and output of 2
39、4-hour period is filled in corresponding column of the temperature sheet.,Recording fluid intake and out,出入液量记录单,姓名 床号 诊断 科别 病房 住院号,出入液量记录单 入量 出量项目量,护理文书书写课件,4.Recording special nursing,Special nursing record made by nurses provides information about conditions of a severely ill client or postoperat
40、ive client, treatment and nursing care provided, and progress toward achieving desired outcomes according to the physicians orders and clients conditions.,4.Recording special nursingSp,special nursing record,Contents of recordInformation commonly found in the special nursing record sheet includes a
41、clients basic demographic data(e.g., name, age, ward number, bed number, and admission hospital number),vital signs, level of consciousness, fluid intake and output, state of illness, nursing intervention, response to medication, and signature. Documentation of nursing care for critically ill client
42、 should be specified according to medical specialty.,special nursing recordConte,护理文书书写课件,Methods and recommendations for recordingAll the parts must be recorded with a blue-black inked penRecord is made objectively according to current physicians and changes of clients conditions.Recording should b
43、e timely and exact in reflecting the changes of the clients conditions.,special nursing record,go,Methods and recommendations fo,Methods and recommendations for recordingIt is unnecessary to chart a routine daily care, such as changing bed and morning care.Routinely measured vital signs are drawn in
44、 the temperature sheet.It is improper to copy the physicians note.Record should be complete and legible.The clients total intake and output, conditions, treatment and care are summarized at the end of each 12-hour and 24-hour period.,special nursing record,go,Methods and recommendations fo,5.Reporti
45、ng clients conditions,Clients condition report is a written report in which the nurses give information about dynamic changes of clients conditions during the period of their shift.Components of reportDischarge, transfer-out, and death reportAdmission, transfer-in reportSeverely ill clients reportPo
46、stoperative clients reportPre-operation, pre-diagnostic studies preparation report.,5.Reporting clients condition,书写顺序用蓝钢笔填写眉栏所列的各项 根据下列顺序，按床号先后书写出科（出院、转出、死亡）入科（入院、转入）病重（病危）、当日手术患者、病情变化患者、次日手术及特殊治疗检查患者、外出请假及其他有特殊情况的患者。,Reporting clients conditions,书写顺序Reporting clients conditi,书写要求应在经常巡视和了解病情的基础上书写；
47、白班用蓝黑、碳素墨水笔填写，夜间用红色笔填写。书写内容应全面、真实、简明扼要、重点突出；眉栏项目包括当日住院患者总数、出院、入院、手术、分娩、病危、病重、抢救、死亡等患者数。填写时，先写姓名、床号、诊断；后报告生命体征，并注明时间；再简要记录病情、治疗和护理；对新入院、转入、手术、分娩患者，在诊断的右下方用红笔注明“新”“转入”“手术”“分娩”，危重患者做红色标记“*”或“危”；写完后注明页数并签名；护士长应每班检查，符合质量后签全名。,Reporting clients conditions,书写要求Reporting clients conditi,书写要求,出科患者：记录床号、姓名、诊断
48、、转归。入科患者及转入患者：记录床号、姓名、诊断及重点交接内容。其重点内容为主要病情、护理要点（管道情况、皮肤完整性、异常心理及其护理安全隐患等）、后续治疗及观察。病重（病危）患者：记录床号、姓名、诊断。病情变化等记录在病重（病危）患者护理记录单上。 手术患者：记录手术名称、回病房的时间、当班实施的护理措施、术后观察要点及延续的治疗等。病情变化的患者：记录本班主要病情变化、护理措施及下一班次护理观察要点和后续治疗。,书写要求,书写要求,次日手术的患者：记录术前准备，交待下一班次观察要点及相关术前准备情况等。特殊治疗的患者：记录所做治疗的名称、护理观察要点及注意事项。特殊检查的患者：记录检查项目
49、、时间、检查前准备及观察要点等。外出请假的患者：记录去向、请假时间、医生意见、告知内容等。其他：患者有其他特殊及异常情况时要注意严格交接班，如情绪或行为异常、跌倒、摔伤等不良事件等。,书写要求 次日手术的患者：记录术前准备，交待下一班次,2010,2010,This part mainly introduces different formats in nursing history. The techniques of how to apply nursing process in data collection, planning, intervention and evaluation.
50、Forms used for nursing historyAdmission assessment sheetImpatient assessment sheetNursing plan sheetNursing record sheetHealth education plan sheet,6.Nursing history,This part mainly introduces di,60,Nursing history,Admission assessment sheet用于对新入院患者进行的初步护理评估，并通过评估找出患者的健康问题，确立护理诊断。主要内容包括患者的一般资料、现在健康
