护理英文护理文件书写

Chapter16

NursingDocumentation

第1页medicalandnursingdocumentsclient'srecordAclient'smedicalrecordTemperaturesheetPhysician’sordersheetspecialnursingrecordchart,etc.Change-of-shiftreport(病室交班汇报)第2页Section1RecordandAdministration

ofmedicalandNursingDocumentsPurposeofRecordsPrincipleofRecordsAdministrationofMedicalandNursingDocuments第3页PurposeofRecords

ProvidingInformationProvidingBasisforQualityReviewProvidingBasisforLegalPurposeProvidingDataforEducationandResearch第4页PrinciplesofRecords

Timely1ObjectiveandAccurate2Complete3Concise4Legible5第5页followthehospital’srequirementtomakedocumentationatregularintervals.Norecordingshouldbedonebeforeprovidingnursingcares,anddelayingoromittingtherecordingisnotacceptableeither.

Timely1第6页

ObjectiveandAccurate

2Recordingmustbeaccurateandcorrect.Accuraterecordingsconsistoffactsorobservationsratherthanopinionsorinterpretation.第7页Theclient'sname,age,andbednumber,shouldbewrittenoneachpageoftherecord.

Complete3Leavingnoblanklinesontheclient'schart.thecaregivermustsignhisorherfullnameafterrecording.aclient'sconditioniscritical.aclientinsistsonrefusingatreatmentorleavingthehospitalagainstmedicaladvice.aclienthasinclinationofmittingsuicide.thesesituationsmustbefilledintheclient'schart.第8页

Concise4Documentationmustbeconcise,inalogicalorder,andlaystressonkeypoints.第9页Allentriesmustbelegibleandeasytoread.Whenarecordingerrorismade,drawalinethroughitandwritethecorrector'snameaboveit.Donoterase,blotout,orusecorrectionfluid.

Legible5第10页Administrationof

MedicalandNursingDocumentsAdministrationRequirementsArrangementOrderofMedicalRecord第11页AdministrationRequirements第12页Allmedicalandnursingdocumentsshouldbeplacedaccordingtoorganizationguidelines.Theyshouldbereplacedafterbeingreadorrecorded.第13页Medicalandnursingdocumentsmustbekeptneatly,orderly,pletelyandpreventthemfrombeingcontaminated,mangled,disconnectedandlost.第14页Theclientortheclient'sfamilyshouldnotreadthemedicalandnursingdocumentsfreely.Nocarryingthedocumentsoutofthewardwithoutbeingpermitted.Ifthedocumentsneedtobecarriedoutofthewardforthepurposeofmedicalactivityorcopy,itshouldbecarriedandkeptwellbyhospitalappointedstaff.第15页Allthedocumentsshouldbekeptproperly.Whentheclientisdischargedfromthehospital,temperaturesheet,physician’sordersheetandspecialnursingrecordchartwillbekeptpermanentlyinMedicalRecordingRoomofthehospitalaspartsoftheclient'scase-notes.Thechange-of-shiftreportwillbekeptatleastoneyearatthewardlevel.第16页ArrangementOrderofMedicalRecordOrderofAdmissionRecordOrderofDischarge(transfer,death)Record第17页OrderofAdmissionRecordTemperaturesheetPhysician’sordersheetAdmissionsheetandrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsSpecialnursingrecordFirstpageofclientrecordAdmissionsheetOutpatientrecord第18页OrderofDischarge(transfer,death)RecordFirstpageofclientrecordAdmissionsheet(ifclientdied,addingdeathreportsheet)DischargeordeathrecordAdmissionrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsspecialnursingrecordPhysician’sordersheetTemperaturesheet

Outpatientrecordisgivenbacktotheclientortheclient'sfamily.第19页Section2WritingNursingDocumentsTemperatureSheetManagingPhysician’sOrderRecordingSpecialnursingReportingClient’sConditions第20页中国医疗信息化旳发展

医院信息系统(hospitalinformationsystem,HIS)面向临床工作旳医院临床信息系统(clinicalinformationsystem,CIS)将成为HIS旳重点发展方向。CIS波及电子病历系统、医学影像处理系统、试验室数据处理系统、临床专科数据分析系统等。第21页TemperatureSheetItisonthefirstpageofclient'shospitalizationrecord.itprovidesthestaffwithaquicksummaryofalltheclient'sconditionandvitalsignsonthesheet.第22页第23页FillinginTopPartThispartmustbefilledinwithablue-blackinkedorcarboninkedpen.Client'sname,sex,age,ward,admissiondateandhospitalizationnumbermustbefilledinpletely.year,monthanddaymustbefilledinthefirstdaycolumnofeverypage.therestsixdayscolumnonly“Day”第24页FillinginBetween40℃~42℃

ColumnofTemperatureSheetTimeofadmission,operation,childbirth,transfer,dischargeordeathisfilledintheverticallineofcorrespondingtimecolumnwitharedinkedpenbetween40℃~42℃column.itisessentialtospecifytheminute.Ifthetimeisnotequaltothetimeattemperaturesheet,fillintheproximaltimecolumn.第25页DrawingBodyTemperatureCurveDrawingSphygmogram第26页DrawingBodyTemperatureCurveOraltemperature:“●”，Axillarytemperature

“×，Rectaltemperature

“○”.Twoadjacentreadingsareconnectedbyblueline.第27页Aclientwithhyperpyrexianeedstohavethebodytemperaturetakenagaininhalfanhour

afterreceivingphysicaltherapy.Thereadingofmeasuredtemperatureisdrawninthesamelongitudinalcolumnofpreviousreadingbyred“○”,andconnectedwiththereadingbeforephysicaltherapybyreddottedline.Thereadingofnextmeasurementisstillconnectedwiththereadingbeforephysicaltherapy.

第28页aclient'sbodytemperatureisbelow35℃不升不升Readingofmeasuredtemperatureisrepresentedbyblue“×”,andconnectedwiththe

adjacentreadings.第29页DrawingSphygmogramPulserateisdrawninred“●”,Twocorrespondingreadingsofpulserateareconnectedbyredline.第30页pulsedeficitheartrateisinred“○”.Twocorrespondingreadingsofheartrateareconnectedbyredline.filledintheareabetweenthelineofpulserateandthelineofheartrateinredline.第31页Ifthereadingofbodytemperatureandpulserateareatthesamepoint,drawthetemperaturefirstinblue“×”,thendrawaredcircle(○)outsidetheblue“×”torepresentthepulserate.第32页Respiration

ReadingsofrespirationarerecordedincorrespondingtimecolumnsinArabicnumberwithbluepenandthenumbersarewrittenalternativelyupwardanddownward.第33页FillinginBottomPart

Allthispartisfilledinbyusingablue-blackinkedorcarboninkedpen.Arabicnumberrepresentsthereadings.Calculationunitisomitted.Contents：第34页BowelMovement

Documentthebowelmovementonthepreviousday.Ifthereisnobowelmovement,document"0";fecalincontinenceisdocumentedas"※";“E”representsenema.(0/E;11/E)Documentthenumberoftimesonceaday1/Erepresentsonetimeofdefecationafterenema.第35页FluidintakeandoutputDocumentthetotalamountofFluidintakeandoutputofthepreviousday(duringa24-hourperiod)accordingtothephysician'sorder.theamountofintakeandoutputfluidsarerecordedinml.FluidoutputFluidIntake第36页BloodPressureIfmoremeasuringisneeded,thereadingsofmeasurementcanberecordedinthenursingnotes.Readingsofbloodpressurearerecordedincorrespondingtimecolumns.110/75,105/70第37页BodyWeightFillitintheunitofkg.Whenaclientisadmitted,thenursemeasureshisorherbodyweightanddocumentsitinthecorrespondingtimecolumn.Duringhospitalization,measureanddocumentbodyweightonceaweek.第38页daysofoperation(childbirth)

Thenextdayofoperation(childbirth)isregardedasthefirstdayofoperation(childbirth)thathasbeenchartedcontinuouslyonthedaycolumninArabicnumber“1,2,3...”until10days.Ifasecondoperationhasbeendonewithin10days第39页DaysofhospitalizationwriteinArabicnumber“1,2,3...”fromthedayofadmissiontothedayofdischarge.第40页PageNumberFillthepagenumbersinsequence.第41页ManagingPhysician’sOrderphysicianorderrecordingbook(医嘱本)

physicianordersheet(医嘱单)varioustypesofformsthatarenecessaryforimplementation

(多种执行单)第42页physicianorderrecordingbook床号姓名时间医嘱医生执行护士签名时间签名2023-12-111-3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

2023-12-121-3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第43页physicianordersheetSTATorderSheetStandingorderSheet第44页第45页varioustypesofforms

thatarenecessaryforimplementationnursinggradesheetdietsheetoralmedicationsheetinjectionsheettreatmentsheet,etc.口服药1-3张利8–12–4Vc100mg土霉素0.5

8pm土霉素0.5第46页ContentsofPhysicianOrderDate,Time,BedNo,Name

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

physician'ssignaturenurse'ssignature第47页TypesofPhysicianOrderStandingOrderSTATOrderPRNOrderSOSOrder第48页StandingOrderAstandingorder

isvaliduntilitiscancelledbythephysician.Usuallythevalidtimeofastandingorderexceeds24hours.第49页STATOrderThevalidtimelimitofaSTATorder

iswithin24hours,usuallyonlyonce.SometimesaSTAT(ST)ordersignifiesthatasingledoseofmedicationistobegivenimmediately.安定5mghs.第50页PRNOrderPRNorderisakindofstandingorder.ThephysicianmayorderatreatmentonaPRNbasisiftheclient'sconditionneeds.Oftenthephysiciansetsminimalintervalsbetweentwotimesofadministration.度冷丁50mgimq6hprn第51页SOSOrderThevalidtimeoftheSOSorderiswithin12hours.Itwillbecarriedoutonlyonceasthestateofanillnessneeds.Itbeesinvalidifitexceedsthetimelimit.第52页ManagingPhysicianOrder

MethodofHandlingPrinciplesofManaging第53页StandingOrdertransferstheordersontovarioustypesofforms.Thestandingorderstransferredontotheimplementationformswhicharecarriedoutinappointedtimeshouldbesignedspecificadministeredtime.第54页PRNordertransfersthemontovarioustypesofforms.Ifthephysiciansetsminimalintervalsbetweentwotimesofadministration,eachtimethenursecarriesoutthePRNorder,heorshehastodocumenttheexacttimeandsignfullname.第55页STATOrder“st”meansexecutinganorderimmediately.Aftercarryingouttheorder,thenursehastosignhisorhernamein“executer”columnandnotesthetimeofexecuting.penicillinpositive(＋)negative(－)penicillinskintest第56页SOSorderSOSordershouldbecarriedoutonlyonceasthestateofanillnessneeds.Theperson,whocarriesouttheorder,signshisorhernamein“performer”columnandnotesthetimeofexecuting.Theorderbeesinvalidifitexceedsthetimelimit.Thenursewritestheword“unexecuted”,documentsthetimeandsignshername.第57页StoptheOrderIfaphysiciandecidestostopanorderforsomereasons,thenursecancelstheorderinrelatedtreatmentsheetfirst.writedownthedateandtimein“stop”columninphysicianordersheet.第58页Re-arrangingtheOrderdrawaredlinebelowthelastrowofphysicianorders,write“Rearranging”inthemiddlebelowtheredlinewitharedpen,andtranscribeoriginalvalidphysicianordersontospacesbelowtheredline.Twonursesverifytherearrangedordersandsigntheirnames.Aftertheoperation,childbirthortransferring,physicianordershavetoberearrangedtoo.Drawaredlinebelowthelastrowoforiginalorders,andwrite“post-operationorder”,“post-childbirthorder”,第59页UrgentBeforeRoutine.Whenmanagingseveralphysicianorders,itisnecessarytoseewhichorderismoreimportantorurgenttotheclient,andgivepriorityforcarryingitout.PrinciplesofManaging第60页STATOrderBeforeStandingOrder.

ItisroutinetocarryoutaSTATorderbeforeastandingone.PrinciplesofManaging第61页Theordercouldnotbechanged.Ifitistobecanceled,note“cancel”witharedpenandsign.PrinciplesofManaging第62页Generallyspeaking,thephysicianshouldnotgiveoralorders.Intheeventsofanemergencyorduringoperationwhenthephysiciangivesordersorallytonurses,thenurseshavetorepeattheorderonceagainandmakesureitiscorrect.Aftertheemergencyhasbeenallayedandthephysicianshouldrecordandsignallordersthatweregiven.PrinciplesofManaging第63页IfaSTATorSOSorderistobecarriedoutonthenextshift,theordershouldbewrittendowninthenursingnotes.PrinciplesofManaging第64页Thephysicianordersmustbecheckedineveryshiftandtotallyonceeveryweek.PrinciplesofManaging第65页clinicalinformationsystem,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第66页RecordingFluidIntakeandOutputContentsMethodsforRecording第67页Contents出入液量记录单fluidintakefluidoutputoralfluidintakefoodintakeintravenousfluidinfusions

urine,stool,vomit,bleeding,sputum,gastricsuction,anddrainagefrompost-surgicaldrainagetubes.

第68页第69页Daytime'sfluidintakeandoutput

arerecordedwithablue-blackinkedorcarboninkedpen;nighttime'sfluidintakeandoutput

arerecordedwitha

akeandoutput

aresummarizedattheendofeach12-hourand24-hourperiod.Sum

ofintakeandoutputof24-hourperiodisfilledincorrespondingcolumnofthetemperaturesheet.MethodsforRecording第70页RecordingSpecialNursingContentsofrecordMethodsandRemendationsforRecording第71页Contentsofrecordvitalsignslevelofconsciousnessfluidintakeandoutputstateofillnessnursinginterventionresponsetomedicationsignature第72页MethodsandRemendations尤其护理记录单第73页第74页Change-of-shiftreportComponentsofReportRemendations第75页ComponentsofReportDischarge,Transfer-out,andDeathReportAdmission,Transfer-inReportSeverelyIllClients'ReportPostoperativeClients'ReportPre-operation,pre-diagnosticStudiesPreparationReport第76页TopPart

OrderofWriting

Warddatetimetotalnumberofclients

numberofclientadmission

discharge

transferOperation

childbirth

clientsincriticalstatedeath.discharge,transfer-out,deathadmission,transfer-inoperativeclients,clientswhogivesbirth,criticallyillclients,andclientsofunusualcondition第77页第78页病人状况日夜汇报

日期—年—月—日护士长签字：姓名入院病重床号