1、Nursing DocumentationNursing Documentationpurpose of recordscommunicatingProviding theoretical basis for planning client treatment and careProviding data for education and researchProviding basis for quality reviewProviding basis for legal purposepurpose of recordscommunicatprinciple of record1、reco

2、rding procedures in time2、accuracy3、completeness4、objectivity5、well-organized presentationprinciple of record1、recordi醫(yī)療與護理文件的管理管理要求各種護理文件按規(guī)定放置，記錄和使用后必須放回必須保持醫(yī)療護理文件的清潔、整齊、完整、防止污染、破損、拆散、丟失患者和家屬不得隨意翻閱醫(yī)療護理文件的記錄資料，不得擅自將醫(yī)療護理文件帶出病區(qū)醫(yī)療文件應(yīng)妥善保存：出院或死亡的病案應(yīng)整理后交病案室，并按衛(wèi)生行政部門規(guī)定的保存期限保管。體溫單、醫(yī)囑單、特別護理記錄單長期保存。病區(qū)交班報告本保存1

3、年，以備查閱。發(fā)生醫(yī)療事故糾紛時，應(yīng)在醫(yī)患雙方同時在場的情況下封存，并由醫(yī)療機構(gòu)負責(zé)醫(yī)療服務(wù)質(zhì)量監(jiān)控的部門或?qū)Ｂ毴藛T保管。醫(yī)療與護理文件的管理管理要求 放置位置病歷夾病歷車病案室 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 studies reports8、nur

4、ses record9、standing order execute sheet10、first page of client record11、outpatient recordorder 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 record7、 diagnostic

5、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護理文書書寫課件護理文書書寫課件writing nursing documents1、temperature sheet2、managing physicians order3、recor

6、ding fluid intake and output4、recording special nursing5、reporting clients conditions6、nursing historywriting nursing documents1、tem1、temperature sheetThe temperature sheet is used to record the temperature, pulse, respiration, blood pressure, body weight, fluid intake and output, urine, bowel movem

7、ents, 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 temperaThis part must be filled in with a blue-inked or carbon inked pen.Clients name, age, ward, bed number, admission date and time

8、, 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 filled in if a new month or a

9、 new year starts within the six days.Filling in top partThis part must be filled in wi4、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 operation (childbirth) that has

10、 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 operation in Arabic number until the

11、14days.Filling in top part4、Days of hospitalization are 眉欄濟寧醫(yī)學(xué)院附屬張三心內(nèi)科5床2010-12-296875362010-12-2930312011-01-0123234567123(2)411/4體溫記錄單 眉欄濟寧醫(yī)學(xué)院附屬張三心內(nèi)科5床2010-12Filling in between 40 -42 column of temperature sheetThis part is filled in with a blue-black inked or carbon inked pen.Time of admission, o

12、peration, 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 minuteFilling in between 40 -42 cFilling in between 40 -42 column

13、of temperature sheetMethod 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 proximal time column. For example, if admission is at 11 oclock, t

14、hen 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 c4042橫線之間入院-八時二十分分娩于二十時十三分轉(zhuǎn)出-九時二十分出院-十五時三十分4042橫線之間入院-八時二十分分娩于二十時十三分轉(zhuǎn)出Drawing body temperature curve and sphygmogramOral temperature is represented by blue “

15、 ” ,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 client with hyperpyrexia needs to have his or her body temperature tak

16、en 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 curvegoDrawing body temperature curve體溫的繪制T曲線繪制v不升體溫的繪制T曲線繪制v不升Drawing sphygmogramPu

17、lse 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 xDrawing sphygmogramPulse rate 脈搏的繪制P、心率曲線繪制脈搏短絀脈搏的繪制P、心率曲線繪制脈搏短絀Respiration Readings o

18、f respiration are recorded in corresponding time columns.It is filled in by using a blue-black inked or carbon inked pen.1818192022191818Respiration Readings of respir體溫單34以下各欄目，用藍黑、碳素墨水筆填寫。體溫單34以下各欄目，用藍黑、碳素墨水筆填寫。Filling in bottom partBlood pressureBody weightBowel movementIntravenous infusion fluid

19、 and urinePage numberFilling in bottom partBlood pr底欄底欄2.Managing physicians order The physicians order is usually a written order prescribed by the physician in the process of treatment.Contents of physicians order：Date, time, routine care. Grade of nursing, diet. Body position, medication (name, d

20、osage), routes of administration, physicians signature, and nurses signature.2.Managing physicians order T醫(yī)囑范例：呼吸內(nèi)科護理常規(guī)一級護理低脂飲食吸氧 prn 5%葡萄糖 250ml氨茶堿 500mg速尿20mg iv st 舒樂安定 5mg. po.sos明晨禁食行B超檢查 2013-10-19 9:00am張平ivgtt.qd醫(yī)囑范例：呼吸內(nèi)科護理常規(guī)2013-10-19 9:00amstanding order：a standing order is valid until it

21、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一級護理心內(nèi)科護理常規(guī)低鹽飲食消心痛10mg po tid一級護理半流質(zhì)飲食10%葡萄糖250ml+氨芐西林3.0g ivgtt qdstanding order：a standing ordstat order：a STAT order signifies that a single

22、 dose of medication is to be given immediately, usually only once. The valid time limit of a STAT order is within 24 hours.需立即執(zhí)行，阿托品0.5mg H. st .需在限定時間內(nèi)執(zhí)行，會診、手術(shù)、血、尿、糞常規(guī)檢查，X線攝片及各項特殊檢查等出院、轉(zhuǎn)科、死亡也屬于臨時醫(yī)囑需一日內(nèi)連續(xù)用藥數(shù)次者，按臨時醫(yī)囑處理。如奎尼丁0.2g po q2h5Types of physicians orderstat order：a STAT order signiTypes of phy

23、sicians order備用醫(yī)囑： (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 intervals between two times of administration. This means that a drug cannot be given more frequently than what is pr

24、escribed. An example of PRN order is Dolantin(杜冷丁) 50mg IM q6h prn.Types of physicians order備用醫(yī)囑Types of physicians order備用醫(yī)囑： (2) sos order: the valid time of the SOS order is within 12 hours. It will be carried out only once as the state of an illness needs. It becomes invalid if it exceeds the ti

25、me limit, for example, Dolantin 50mg IM SOS.Types of physicians order備用醫(yī)囑護士簽名李麗劉鳳維生素B110mg po tid、維生素E0.1g po tid、測BP、pq6h劉鳳9:0005-04、青霉素80萬u imbid、半流質(zhì)飲食、二級護理內(nèi)科常規(guī)護理9:002010-05-02醫(yī)師簽名時間日期時間日期停 止護士簽名醫(yī)師簽名 醫(yī)囑內(nèi)容 開 始長期醫(yī)囑單姓名 陳敏 病區(qū) 內(nèi)科 床號 5床 住院號20100578劉鳳護士簽名李麗劉鳳維生素B110mg po tid、維生素E臨時醫(yī)囑單姓名 陳敏 病區(qū) 內(nèi)科 床號 5床 住院

26、號20100578時 間日 期劉鳳X線胸片、心電圖、小便常規(guī)、大便常規(guī)、血常規(guī)、明晨抽血測k、安定10mg im sos、阿托品0.5mg im st青霉素皮試（ ）9:002010-05-02執(zhí)行者簽名執(zhí)行時間醫(yī)師簽名醫(yī) 囑 內(nèi) 容 開 始劉鳳臨時醫(yī)囑單姓名 陳敏 病區(qū) 內(nèi)科 長期醫(yī)囑處理護士將長期醫(yī)囑單上的醫(yī)囑分別轉(zhuǎn)抄至各種執(zhí)行卡上，轉(zhuǎn)抄時須注明執(zhí)行的具體時間并簽全名。護士執(zhí)行長期醫(yī)囑后應(yīng)在長期醫(yī)囑執(zhí)行單上注明執(zhí)行的時間，并簽全名。Managing physicians order長期醫(yī)囑處理Managing physicians ord護士簽名劉鳳維生素B110mg po tid、維生素

27、E0.1g po tid、測BP、pq6h李麗、青霉素80萬im bid、半流質(zhì)飲食、二級護理劉鳳內(nèi)科常規(guī)護理9:002010-05-02醫(yī)師簽名時間日期時間日期停 止護士簽名醫(yī)師簽名 醫(yī)囑內(nèi)容 開 始長期醫(yī)囑單姓名 陳敏 病區(qū) 內(nèi)科 床號 5床 住院號20100578護士將長期醫(yī)囑欄內(nèi)的醫(yī)囑分別轉(zhuǎn)抄至各種執(zhí)行單上(如服藥單、注射單、輸液單、飲食單等)肌注卡 姓名 陳敏 科室 內(nèi) 床號 30 青霉素80萬 im 8-4pm轉(zhuǎn)抄后在醫(yī)囑單上簽全名護士簽名劉鳳維生素B110mg po tid、維生素E0.臨時醫(yī)囑處理需立即執(zhí)行的醫(yī)囑，護士執(zhí)行后，必須注明執(zhí)行時間并簽上全名。有限定執(zhí)行時間的臨時醫(yī)囑

28、，護士應(yīng)及時轉(zhuǎn)抄至臨時治療本或交班記錄本上。會診、手術(shù)、檢查等各種申請單應(yīng)及時送到相應(yīng)科室。 Managing physicians order臨時醫(yī)囑處理Managing physicians ord臨時醫(yī)囑單姓名 陳敏 病區(qū) 內(nèi)科 床號 5床 住院號20100578時 間日 期劉鳳X線胸片、心電圖、小便常規(guī)、大便常規(guī)、血常規(guī)、明晨抽血測k、安定10mg im sos王蘭、阿托品0.5mg im st9:30劉鳳青霉素皮試（ ）9:002010-05-02執(zhí)行者簽名執(zhí)行時間醫(yī)師簽名醫(yī) 囑 內(nèi) 容 開 始寫在臨時醫(yī)囑欄內(nèi)，護士在執(zhí)行后，必須寫上執(zhí)行時間并簽全名。 臨時醫(yī)囑單姓名 陳敏 病區(qū) 內(nèi)

29、科 備用醫(yī)囑處理長期備用醫(yī)囑：由醫(yī)生開寫在長期醫(yī)囑單上，必須注明執(zhí)行時間。如哌替啶50mg im q6h prn。護士每次執(zhí)行后，在臨時醫(yī)囑單內(nèi)記錄執(zhí)行時間并簽全名，以供下一班參考。臨時備用醫(yī)囑：由醫(yī)生開寫在臨時醫(yī)囑單上，12h內(nèi)有效。地西泮5mg po sos ,若過時未執(zhí)行，則由護士用紅筆在該項醫(yī)囑欄內(nèi)寫“未用”二字。Managing physicians order備用醫(yī)囑處理Managing physicians ord停止醫(yī)囑處理把相應(yīng)執(zhí)行單上的有關(guān)項目注銷，同時注明停止日期和時間在醫(yī)囑單原醫(yī)囑后，填寫停止日期、時間，最后在執(zhí)行者欄內(nèi)簽全名Managing physicians or

30、der停止醫(yī)囑處理Managing physicians ordManaging physicians order重整醫(yī)囑處理：凡長期醫(yī)囑單超過3張，或醫(yī)囑調(diào)整項目較多時需重整醫(yī)囑。由醫(yī)生在原醫(yī)囑最后一行下面劃一紅橫線，在紅線下用紅筆寫“重整醫(yī)囑”（ “術(shù)后醫(yī)囑”、“分娩醫(yī)囑”、“轉(zhuǎn)入醫(yī)囑”等），再將紅線以上有效的長期醫(yī)囑，按原日期、時間的排列順序抄于紅線下。抄錄完畢核對無誤后簽上全名。醫(yī)生重整醫(yī)囑后，由當(dāng)班護士核對無誤后在整理之后的有效醫(yī)囑執(zhí)行者欄內(nèi)簽上全名。Managing physicians order重整醫(yī)囑Executing before transcribingUrgent be

31、fore routineSTAT Order before STANDING Order One order only includes one subject, 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 s

32、hould not give oral orders. If a STAT or SOS order is to be carried out on the next shift, the order should be written down in the nursing notes.Principles of managingPrinciples of managingAfter transcription or rearrangement, the orders have to be checked by two nurses with their signatures. The ph

33、ysicians orders must be checked in every shift and totally once every week.Person who carries out the physicians order has to sign his or her full name in the treatment sheet and physicians order sheet.Principles of managingPrinciples of managing3.Recording fluid intake and outputA healthy adult can

34、 usually maintain normal intake and output fluid balance. Imbalances may occur if a client has cardiovascular disease, renal disease, severe burns, hemorrhage, or extensive surgery.3.Recording fluid intake and oRecording fluid intake and outputfluid intakeFluid intake includes daily oral fluid intak

35、e, food intake, and intravenous fluid infusions etc.fluid outputThe 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 outRecording fluid intake and out

36、putMethods for recordingThe heading must be documented with blue-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.Re

37、cording fluid intake and outRecording fluid intake and outputMethods 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

38、each 12-hour and 24-hour period. Sum of intake and output of 24-hour period is filled in corresponding column of the temperature sheet.Recording fluid intake and out出入液量記錄單日期時間 入量 出量簽名項目量（ml)項目 量（ml)、07:00、19：0012h小結(jié)、07：0024h總結(jié)姓名 床號 診斷 科別 病房 住院號 出入液量記錄單 入量 出量項目量護理文書書寫課件4.Recording special nursingSpe

39、cial nursing record made by nurses provides information about conditions of a severely ill client or postoperative client, treatment and nursing care provided, and progress toward achieving desired outcomes according to the physicians orders and clients conditions.4.Recording special nursingSpspecia

40、l nursing recordContents of recordInformation commonly found in the special nursing record sheet includes a 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

41、intervention, response to medication, and signature. Documentation of nursing care for critically ill client should be specified according to medical specialty.special nursing recordConte護理文書書寫課件Methods and recommendations for recordingAll the parts must be recorded with a blue-black inked penRecord

42、 is made objectively according to current physicians and changes of clients conditions.Recording should be timely and exact in reflecting the changes of the clients conditions. special nursing recordgoMethods and recommendations foMethods and recommendations for recordingIt is unnecessary to chart a

43、 routine daily care, such as changing bed and morning care.Routinely measured vital signs are drawn in 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

44、of each 12-hour and 24-hour period. special nursing recordgoMethods and recommendations fo5.Reporting clients conditionsClients 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 reportD

45、ischarge, transfer-out, and death reportAdmission, transfer-in reportSeverely ill clients reportPostoperative clients reportPre-operation, pre-diagnostic studies preparation report.5.Reporting clients condition書寫順序用藍鋼筆填寫眉欄所列的各項 根據(jù)下列順序，按床號先后書寫出科（出院、轉(zhuǎn)出、死亡）入科（入院、轉(zhuǎn)入）病重（病危）、當(dāng)日手術(shù)患者、病情變化患者、次日手術(shù)及特殊治療檢查患者、外出

46、請假及其他有特殊情況的患者。Reporting clients conditions書寫順序Reporting clients conditi書寫要求應(yīng)在經(jīng)常巡視和了解病情的基礎(chǔ)上書寫；白班用藍黑、碳素墨水筆填寫，夜間用紅色筆填寫。書寫內(nèi)容應(yīng)全面、真實、簡明扼要、重點突出；眉欄項目包括當(dāng)日住院患者總數(shù)、出院、入院、手術(shù)、分娩、病危、病重、搶救、死亡等患者數(shù)。填寫時，先寫姓名、床號、診斷；后報告生命體征，并注明時間；再簡要記錄病情、治療和護理；對新入院、轉(zhuǎn)入、手術(shù)、分娩患者，在診斷的右下方用紅筆注明“新”“轉(zhuǎn)入”“手術(shù)”“分娩”，危重患者做紅色標(biāo)記“*”或“?！保粚懲旰笞⒚黜摂?shù)并簽名；護士長應(yīng)每班檢查，符合質(zhì)量后簽全名。Reporting clients conditions書寫要求Reporting clients conditi書寫要求出科患者：記錄床號、姓名、診斷、轉(zhuǎn)歸。入科患者及轉(zhuǎn)入患者：記錄床號、姓名、診斷及重點交接內(nèi)容。其重點內(nèi)容為主要病情、護