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Chapter16

NursingDocumentation

1Chapter16

NursingDocumentmedicalandnursingdocumentsclient'srecordAclient'smedicalrecordTemperaturesheetPhysician’sordersheetspecialnursingrecordchart,etc.Change-of-shiftreport(病室交班报告)

2medicalandnursingdocumentscSection1RecordandAdministration

ofmedicalandNursingDocumentsPurposeofRecordsPrincipleofRecordsAdministrationofMedicalandNursingDocuments3Section1RecordandAdminPurposeofRecords

ProvidingInformationProvidingBasisforQualityReviewProvidingBasisforLegalPurposeProvidingDataforEducationandResearch4PurposeofRecordsProvidingPrinciplesofRecords

Timely1ObjectiveandAccurate2Complete3Concise4Legible55PrinciplesofRecordsfollowthehospital’srequirementtomakedocumentationatregularintervals.Norecordingshouldbedonebeforeprovidingnursingcares,anddelayingoromittingtherecordingisnotacceptableeither.

Timely16followthehospital’srequirem

ObjectiveandAccurate

2Recordingmustbeaccurateandcorrect.Accuraterecordingsconsistoffactsorobservationsratherthanopinionsorinterpretation.7ObjectiveandAccurate2RecoTheclient'sname,age,andbednumber,shouldbewrittenoneachpageoftherecord.

Complete3Leavingnoblanklinesontheclient'schart.thecaregivermustsignhisorherfullnameafterrecording.aclient'sconditioniscritical.aclientinsistsonrefusingatreatmentorleavingthehospitalagainstmedicaladvice.aclienthasinclinationofcommittingsuicide.thesesituationsmustbefilledintheclient'schart.8Theclient'sname,age,andbe大家有疑问的，可以询问和交流可以互相讨论下，但要小声点9大家有疑问的，可以询问和交流可以互相讨论下，但要小声点9

Concise4Documentationmustbeconcise,inalogicalorder,andlaystressonkeypoints.10ConciseAllentriesmustbelegibleandeasytoread.Whenarecordingerrorismade,drawalinethroughitandwritethecorrector'snameaboveit.Donoterase,blotout,orusecorrectionfluid.

Legible511AllentriesmustbelegibleanAdministrationof

MedicalandNursingDocumentsAdministrationRequirementsArrangementOrderofMedicalRecord12Administrationof

MedicalandAdministrationRequirements13AdministrationRequirements13Allmedicalandnursingdocumentsshouldbeplacedaccordingtoorganizationguidelines.Theyshouldbereplacedafterbeingreadorrecorded.1414Medicalandnursingdocumentsmustbekeptneatly,orderly,completelyandpreventthemfrombeingcontaminated,mangled,disconnectedandlost.1515Theclientortheclient'sfamilyshouldnotreadthemedicalandnursingdocumentsfreely.Nocarryingthedocumentsoutofthewardwithoutbeingpermitted.Ifthedocumentsneedtobecarriedoutofthewardforthepurposeofmedicalactivityorcopy,itshouldbecarriedandkeptwellbyhospitalappointedstaff.1616Allthedocumentsshouldbekeptproperly.Whentheclientisdischargedfromthehospital,temperaturesheet,physician’sordersheetandspecialnursingrecordchartwillbekeptpermanentlyinMedicalRecordingRoomofthehospitalaspartsoftheclient'scase-notes.Thechange-of-shiftreportwillbekeptatleastoneyearatthewardlevel.1717ArrangementOrderofMedicalRecordOrderofAdmissionRecordOrderofDischarge(transfer,death)Record18ArrangementOrderofMedicalROrderofAdmissionRecordTemperaturesheetPhysician’sordersheetAdmissionsheetandrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsSpecialnursingrecordFirstpageofclientrecordAdmissionsheetOutpatientrecord19OrderofAdmissionRecordTempeOrderofDischarge(transfer,death)RecordFirstpageofclientrecordAdmissionsheet(ifclientdied,addingdeathreportsheet)DischargeordeathrecordAdmissionrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsspecialnursingrecordPhysician’sordersheetTemperaturesheetOutpatientrecordisgivenbacktotheclientortheclient'sfamily.20OrderofDischarge(transfer,Section2WritingNursingDocumentsTemperatureSheetManagingPhysician’sOrderRecordingSpecialnursingReportingClient’sConditions21Section2WritingNursingDo中国医疗信息化的发展

医院信息系统(hospitalinformationsystem,HIS)面向临床工作的医院临床信息系统(clinicalinformationsystem,CIS)将成为HIS的重点发展方向。CIS包括电子病历系统、医学影像处理系统、实验室数据处理系统、临床专科数据分析系统等。22中国医疗信息化的发展医院信息系统(hospitalinTemperatureSheetItisonthefirstpageofclient'shospitalizationrecord.itprovidesthestaffwithaquicksummaryofalltheclient'sconditionandvitalsignsonthesheet.23TemperatureSheetItisonthe2424FillinginTopPartThispartmustbefilledinwithablue-blackinkedorcarboninkedpen.Client'sname,sex,age,ward,admissiondateandhospitalizationnumbermustbefilledincompletely.year,monthanddaymustbefilledinthefirstdaycolumnofeverypage.therestsixdayscolumnonly“Day”25FillinginTopPartThispartmFillinginBetween40℃~42℃

ColumnofTemperatureSheetTimeofadmission,operation,childbirth,transfer,dischargeordeathisfilledintheverticallineofcorrespondingtimecolumnwitharedinkedpenbetween40℃~42℃column.itisessentialtospecifytheminute.Ifthetimeisnotequaltothetimeattemperaturesheet,fillintheproximaltimecolumn.26FillinginBetween40℃~42℃

CoDrawingBodyTemperatureCurveDrawingSphygmogram2727DrawingBodyTemperatureCurveOraltemperature:“●”，Axillarytemperature

“×，Rectaltemperature“○”.Twoadjacentreadingsareconnectedbyblueline.28DrawingBodyTemperatureCurveAclientwithhyperpyrexianeedstohavethebodytemperaturetakenagaininhalfanhourafterreceivingphysicaltherapy.Thereadingofmeasuredtemperatureisdrawninthesamelongitudinalcolumnofpreviousreadingbyred“○”,andconnectedwiththereadingbeforephysicaltherapybyreddottedline.Thereadingofnextmeasurementisstillconnectedwiththereadingbeforephysicaltherapy.

29Aclientwithhyperpyrexianeeaclient'sbodytemperatureisbelow35℃不升不升Readingofmeasuredtemperatureisrepresentedbyblue“×”,andconnectedwiththe

adjacentreadings.30aclient'sbodytemperatureisDrawingSphygmogramPulserateisdrawninred“●”,Twocorrespondingreadingsofpulserateareconnectedbyredline.31DrawingSphygmogramPulseratepulsedeficitheartrateisinred“○”.Twocorrespondingreadingsofheartrateareconnectedbyredline.filledintheareabetweenthelineofpulserateandthelineofheartrateinredline.32pulsedeficitheartrateisinIfthereadingofbodytemperatureandpulserateareatthesamepoint,drawthetemperaturefirstinblue“×”,thendrawaredcircle(○)outsidetheblue“×”torepresentthepulserate.33IfthereadingofbodytemperaRespiration

ReadingsofrespirationarerecordedincorrespondingtimecolumnsinArabicnumberwithbluepenandthenumbersarewrittenalternativelyupwardanddownward.34RespirationReadingsofrespirFillinginBottomPart

Allthispartisfilledinbyusingablue-blackinkedorcarboninkedpen.Arabicnumberrepresentsthereadings.Calculationunitisomitted.Contents：35FillinginBottomPartBowelMovement

Documentthebowelmovementonthepreviousday.Ifthereisnobowelmovement,document"0";fecalincontinenceisdocumentedas"※";“E”representsenema.(0/E;11/E)Documentthenumberoftimesonceaday1/Erepresentsonetimeofdefecationafterenema.36BowelMovementDocumentFluidintakeandoutputDocumentthetotalamountofFluidintakeandoutputofthepreviousday(duringa24-hourperiod)accordingtothephysician'sorder.theamountofintakeandoutputfluidsarerecordedinml.FluidoutputFluidIntake37FluidintakeandoutputDocumeBloodPressureIfmoremeasuringisneeded,thereadingsofmeasurementcanberecordedinthenursingnotes.Readingsofbloodpressurearerecordedincorrespondingtimecolumns.110/75,105/7038BloodPressureIfmoremeasurinBodyWeightFillitintheunitofkg.Whenaclientisadmitted,thenursemeasureshisorherbodyweightanddocumentsitinthecorrespondingtimecolumn.Duringhospitalization,measureanddocumentbodyweightonceaweek.39BodyWeightFillitintheunitdaysofoperation(childbirth)

Thenextdayofoperation(childbirth)isregardedasthefirstdayofoperation(childbirth)thathasbeenchartedcontinuouslyonthedaycolumninArabicnumber“1,2,3...”until10days.Ifasecondoperationhasbeendonewithin10days40daysofoperation(childbirth)DaysofhospitalizationwriteinArabicnumber“1,2,3...”fromthedayofadmissiontothedayofdischarge.41DaysofhospitalizationwriteiPageNumberFillthepagenumbersinsequence.42PageNumberFillthepagenumbeManagingPhysician’sOrderphysicianorderrecordingbook(医嘱本)

physicianordersheet(医嘱单)varioustypesofformsthatarenecessaryforimplementation(各种执行单)43ManagingPhysician’sOrderphysphysicianorderrecordingbook床号姓名时间医嘱医生执行护士签名时间签名2007-12-111-3张利8am外科护理常规马良李玲Ⅱ级护理流质饮食青霉素皮试（）st8am黄华10%GS500ml

青霉素640万uivdripqd

丁胺卡那0.2imbidVc100mgtid氧气吸入prn李玲

2007-12-121-3张利4pm停Vc100mgtid李玲下午2点胸腔穿刺2pm吕新安定5mghs

度冷丁50mgimq6h李玲∨∨∨医嘱本山东大学齐鲁医院44physicianorderrecordingbookphysicianordersheetSTATorderSheetStandingorderSheet45physicianordersheetSTATorde4646varioustypesofforms

thatarenecessaryforimplementationnursinggradesheetdietsheetoralmedicationsheetinjectionsheettreatmentsheet,etc.口服药1-3张利8–12–4Vc100mg土霉素0.58pm土霉素0.547varioustypesofforms

thataContentsofPhysicianOrderDate,Time,BedNo,Name

routinecaregradeofnursingdietbodypositionmedication(name,dosage,routesofadministration);pre-operationpreparation;diagnosticStudyandtherapy,preparationfordiagnostictestorsurgery

physician'ssignaturenurse'ssignature48ContentsofPhysicianOrderDatTypesofPhysicianOrderStandingOrderSTATOrderPRNOrderSOSOrder49TypesofPhysicianOrderStandiStandingOrderAstandingorder

isvaliduntilitiscancelledbythephysician.Usuallythevalidtimeofastandingorderexceeds24hours.50StandingOrderAstandingorderSTATOrderThevalidtimelimitofaSTATorderiswithin24hours,usuallyonlyonce.SometimesaSTAT(ST)ordersignifiesthatasingledoseofmedicationistobegivenimmediately.安定5mghs.51STATOrderThevalidtimelimitPRNOrderPRNorderisakindofstandingorder.ThephysicianmayorderatreatmentonaPRNbasisiftheclient'sconditionneeds.Oftenthephysiciansetsminimalintervalsbetweentwotimesofadministration.度冷丁50mgimq6hprn52PRNOrderPRNorderisakindoSOSOrderThevalidtimeoftheSOSorderiswithin12hours.Itwillbecarriedoutonlyonceasthestateofanillnessneeds.Itbecomesinvalidifitexceedsthetimelimit.53SOSOrderThevalidtimeoftheManagingPhysicianOrder

MethodofHandlingPrinciplesofManaging54ManagingPhysicianOrderMethoStandingOrdertransferstheordersontovarioustypesofforms.Thestandingorderstransferredontotheimplementationformswhicharecarriedoutinappointedtimeshouldbesignedspecificadministeredtime.55StandingOrdertransferstheoPRNordertransfersthemontovarioustypesofforms.Ifthephysiciansetsminimalintervalsbetweentwotimesofadministration,eachtimethenursecarriesoutthePRNorder,heorshehastodocumenttheexacttimeandsignfullname.56PRNordertransfersthemontovSTATOrder“st”meansexecutinganorderimmediately.Aftercarryingouttheorder,thenursehastosignhisorhernamein“executer”columnandnotesthetimeofexecuting.penicillinpositive(＋)negative(－)penicillinskintest57STATOrder“st”meansexecutingSOSorderSOSordershouldbecarriedoutonlyonceasthestateofanillnessneeds.Theperson,whocarriesouttheorder,signshisorhernamein“performer”columnandnotesthetimeofexecuting.Theorderbecomesinvalidifitexceedsthetimelimit.Thenursewritestheword“unexecuted”,documentsthetimeandsignshername.58SOSorderSOSordershouldbecStoptheOrderIfaphysiciandecidestostopanorderforsomereasons,thenursecancelstheorderinrelatedtreatmentsheetfirst.writedownthedateandtimein“stop”columninphysicianordersheet.59StoptheOrderIfaphysiciandRe-arrangingtheOrderdrawaredlinebelowthelastrowofphysicianorders,write“Rearranging”inthemiddlebelowtheredlinewitharedpen,andtranscribeoriginalvalidphysicianordersontospacesbelowtheredline.Twonursesverifytherearrangedordersandsigntheirnames.Aftertheoperation,childbirthortransferring,physicianordershavetoberearrangedtoo.Drawaredlinebelowthelastrowoforiginalorders,andwrite“post-operationorder”,“post-childbirthorder”,60Re-arrangingtheOrderdrawarUrgentBeforeRoutine.Whenmanagingseveralphysicianorders,itisnecessarytoseewhichorderismoreimportantorurgenttotheclient,andgivepriorityforcarryingitout.PrinciplesofManaging61UrgentBeforeRoutine.PrincipSTATOrderBeforeStandingOrder.

ItisroutinetocarryoutaSTATorderbeforeastandingone.PrinciplesofManaging62STATOrderBeforeStandinTheordercouldnotbechanged.Ifitistobecanceled,note“cancel”witharedpenandsign.PrinciplesofManaging63TheordercouldnotbechangedGenerallyspeaking,thephysicianshouldnotgiveoralorders.Intheeventsofanemergencyorduringoperationwhenthephysiciangivesordersorallytonurses,thenurseshavetorepeattheorderonceagainandmakesureitiscorrect.Aftertheemergencyhasbeenallayedandthephysicianshouldrecordandsignallordersthatweregiven.PrinciplesofManaging64Generallyspeaking,thephysicIfaSTATorSOSorderistobecarriedoutonthenextshift,theordershouldbewrittendowninthenursingnotes.PrinciplesofManaging65IfaSTATorSOSorderistobThephysicianordersmustbecheckedineveryshiftandtotallyonceeveryweek.PrinciplesofManaging66PrinciplesofManaging66clinicalinformationsystem,CIS

医嘱处理

医生登录医生工作站系统,将医嘱按照长期医嘱、临时医嘱、辅助检查、化验等分类录入系统,护士登录护士工作站系统进行处理:审核医嘱执行医嘱打印表单和医嘱单67clinicalinformationsystem,CRecordingFluidIntakeandOutputContentsMethodsforRecording68RecordingFluidIntakeandOutContents出入液量记录单fluidintakefluidoutputoralfluidintakefoodintakeintravenousfluidinfusions

urine,stool,vomit,bleeding,sputum,gastricsuction,anddrainagefrompost-surgicaldrainagetubes.69Contents出入液量记录单fluidintakefl7070Daytime'sfluidintakeandoutputarerecordedwithablue-blackinkedorcarboninkedpen;nighttime'akeandoutputaresummarizedattheendofeach12-hourand24-hourperiod.Sumofintakeandoutputof24-hourperiodisfilledincorrespondingcolumnofthetemperaturesheet.MethodsforRecording71Daytime'sfluidintakeandoutRecordingSpecialNursingContentsofrecordMethodsandRecommendationsforRecording72RecordingSpecialNursingConteContentsofrecordvitalsignslevelofconsciousnessfluidintakeandoutputstateofillnessnursinginterventionresponsetomedicationsignature73Contentsofrecordvitalsigns7MethodsandRecommendations特别护理记录单74MethodsandRecommendations特别护7575Change-of-shiftreportComponentsofReportRecommendations

76Change-of-shiftreportComponenComponentsofReportDischarge,Transfer-out,andDeathReportAdmission,Transfer-inReportSeverelyIllClients'ReportPostoperativeClients'ReportPre-operation,pre-diagnosticStudiesPreparationReport77ComponentsofReportDischarge,TopPart

OrderofWriting

Warddatetimetotalnumberofclients

numberofclientadmission

discharge

transferOperation

childbirth

clientsincriticalstatedeath.discharge,transfer-out,deathadmission,transfer-inoperativeclients,clientswhogivesbirth,criticallyillclients,andclientsofunusualcondition78TopPartOrderofWritingWard7979病人情况日夜报告

日期—年—月—日护士长签字：姓名入院病重床号出院手术同左同左诊断转出死亡3床杜鹃甲状腺瘤住院10天治愈于9am出院5床许威胃癌住院14天于4pm转普外科19床TPRat4pmTPRatTPRat庞月患者患者患者上消化道穿孔并腹膜炎新31床TPRat吴军肺癌手术护理要点：1、

护士签名护士签名护士签名80病人情况日夜报告

日期—年—月—日RecommendationsRecordisonthebasisofsoundobservation.Thereportshouldbeconcise,accurateandobjective,andhighlightimportantpoints.Thereportshouldbeneatandlegible.Donoterase.Daytime'sconditionsarerecordedwithabluepen,andnighttime'sconditionsarerecordedwitharedpen.81RecommendationsRecordisonthEntriesarefilledinthefollowingorders:writedownthebednumbernameanddiagnosisvitalsignsandthetimeofmeasuringtheclients'conditions,treatmentandnursingcareprovided82EntriesarefilledinthefollForclientsnewlyadmitted,transferred-in,havingoperationorchildbirth,writedowntheword“New”,“Transfer”,“Operation”,and“Childbirth”inredunderthewordsofdiagnosis.Forseverelyillclients,itishighlightedbythesymbol“※”,ortheword“criticallyill”inred.83Forclientsnewlyadmitted,trAfterfinishingtherecording,writedownthenumberofpagesandsignfullname.Theheadnurseshouldchecktheclient'sconditionreportofeachshiftandmakesureitmeetsthenursingqualitycriteria,thensignherfullname.84Afterfinishingtherecording,ThankYou!85ThankYou!85Chapter16

NursingDocumentation

86Chapter16

NursingDocumentmedicalandnursingdocumentsclient'srecordAclient'smedicalrecordTemperaturesheetPhysician’sordersheetspecialnursingrecordchart,etc.Change-of-shiftreport(病室交班报告)

87medicalandnursingdocumentscSection1RecordandAdministration

ofmedicalandNursingDocumentsPurposeofRecordsPrincipleofRecordsAdministrationofMedicalandNursingDocuments88Section1RecordandAdminPurposeofRecords

ProvidingInformationProvidingBasisforQualityReviewProvidingBasisforLegalPurposeProvidingDataforEducationandResearch89PurposeofRecordsProvidingPrinciplesofRecords

Timely1ObjectiveandAccurate2Complete3Concise4Legible590PrinciplesofRecordsfollowthehospital’srequirementtomakedocumentationatregularintervals.Norecordingshouldbedonebeforeprovidingnursingcares,anddelayingoromittingtherecordingisnotacceptableeither.

Timely191followthehospital’srequirem

ObjectiveandAccurate

2Recordingmustbeaccurateandcorrect.Accuraterecordingsconsistoffactsorobservationsratherthanopinionsorinterpretation.92ObjectiveandAccurate2RecoTheclient'sname,age,andbednumber,shouldbewrittenoneachpageoftherecord.

Complete3Leavingnoblanklinesontheclient'schart.thecaregivermustsignhisorherfullnameafterrecording.aclient'sconditioniscritical.aclientinsistsonrefusingatreatmentorleavingthehospitalagainstmedicaladvice.aclienthasinclinationofcommittingsuicide.thesesituationsmustbefilledintheclient'schart.93Theclient'sname,age,andbe大家有疑问的，可以询问和交流可以互相讨论下，但要小声点94大家有疑问的，可以询问和交流可以互相讨论下，但要小声点9

Concise4Documentationmustbeconcise,inalogicalorder,andlaystressonkeypoints.95ConciseAllentriesmustbelegibleandeasytoread.Whenarecordingerrorismade,drawalinethroughitandwritethecorrector'snameaboveit.Donoterase,blotout,orusecorrectionfluid.

Legible596AllentriesmustbelegibleanAdministrationof

MedicalandNursingDocumentsAdministrationRequirementsArrangementOrderofMedicalRecord97Administrationof

MedicalandAdministrationRequirements98AdministrationRequirements13Allmedicalandnursingdocumentsshouldbeplacedaccordingtoorganizationguidelines.Theyshouldbereplacedafterbeingreadorrecorded.9914Medicalandnursingdocumentsmustbekeptneatly,orderly,completelyandpreventthemfrombeingcontaminated,mangled,disconnectedandlost.10015Theclientortheclient'sfamilyshouldnotreadthemedicalandnursingdocumentsfreely.Nocarryingthedocumentsoutofthewardwithoutbeingpermitted.Ifthedocumentsneedtobecarriedoutofthewardforthepurposeofmedicalactivityorcopy,itshouldbecarriedandkeptwellbyhospitalappointedstaff.10116Allthedocumentsshouldbekeptproperly.Whentheclientisdischargedfromthehospital,temperaturesheet,physician’sordersheetandspecialnursingrecordchartwillbekeptpermanentlyinMedicalRecordingRoomofthehospitalaspartsoftheclient'scase-notes.Thechange-of-shiftreportwillbekeptatleastoneyearatthewardlevel.10217ArrangementOrderofMedicalRecordOrderofAdmissionRecordOrderofDischarge(transfer,death)Record103ArrangementOrderofMedicalROrderofAdmissionRecordTemperaturesheetPhysician’sordersheetAdmissionsheetandrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsSpecialnursingrecordFirstpageofclientrecordAdmissionsheetOutpatientrecord104OrderofAdmissionRecordTempeOrderofDischarge(transfer,death)RecordFirstpageofclientrecordAdmissionsheet(ifclientdied,addingdeathreportsheet)DischargeordeathrecordAdmissionrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsspecialnursingrecordPhysician’sordersheetTemperaturesheetOutpatientrecordisgivenbacktotheclientortheclient'sfamily.105OrderofDischarge(transfer,Section2WritingNursingDocumentsTemperatureSheetManagingPhysician’sOrderRecordingSpecialnursingReportingClient’sConditions106Section2WritingNursingDo中国医疗信息化的发展

医院信息系统(hospitalinformationsystem,HIS)面向临床工作的医院临床信息系统(clinicalinformationsystem,CIS)将成为HIS的重点发展方向。CIS包括电子病历系统、医学影像处理系统、实验室数据处理系统、临床专科数据分析系统等。107中国医疗信息化的发展医院信息系统(hospitalinTemperatureSheetItisonthefirstpageofclient'shospitalizationrecord.itprovidesthestaffwithaquicksummaryofalltheclient'sconditionandvitalsignsonthesheet.108TemperatureSheetItisonthe10924FillinginTopPartThispartmustbefilledinwithablue-blackinkedorcarboninkedpen.Client'sname,sex,age,ward,admissiondateandhospitalizationnumbermustbefilledincompletely.year,monthanddaymustbefilledinthefirstdaycolumnofeverypage.therestsixdayscolumnonly“Day”110FillinginTopPartThispartmFillinginBetween40℃~42℃

ColumnofTemperatureSheetTimeofadmission,operation,childbirth,transfer,dischargeordeathisfilledintheverticallineofcorrespondingtimecolumnwitharedinkedpenbetween40℃~42℃column.itisessentialtospecifytheminute.Ifthetimeisnotequaltothetimeattemperaturesheet,fillintheproximaltimecolumn.111FillinginBetween40℃~42℃

CoDrawingBodyTemperatureCurveDrawingSphygmogram11227DrawingBodyTemperatureCurveOraltemperature:“●”，Axillarytemperature

“×，Rectaltemperature“○”.Twoadjacentreadingsareconnectedbyblueline.113DrawingBodyTemperatureCurveAclientwithhyperpyrexianeedstohavethebodytemperaturetakenagaininhalfanhourafterreceivingphysicaltherapy.Thereadingofmeasuredtemperatureisdrawninthesamelongitudinalcolumnofpreviousreadingbyred“○”,andconnectedwiththereadingbeforephysicaltherapybyreddottedline.Thereadingofnextmeasurementisstillconnectedwiththereadingbeforephysicaltherapy.

114Aclientwithhyperpyrexianeeaclient'sbodytemperatureisbelow35℃不升不升Readingofmeasuredtemperatureisrepresentedbyblue“×”,andconnectedwiththe

adjacentreadings.115aclient'sbodytemperatureisDrawingSphygmogramPulserateisdrawninred“●”,Twocorrespondingreadingsofpulserateareconnectedbyredline.116DrawingSphygmogramPulseratepulsedeficitheartrateisinred“○”.Twocorrespondingreadingsofheartrateareconnected