Chapter16

NursingDocumentation

1精選Chapter16

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

2精選medicalandnursingdocumentscSection1RecordandAdministration

ofmedicalandNursingDocumentsPurposeofRecordsPrincipleofRecordsAdministrationofMedicalandNursingDocuments3精選Section1RecordandAdminPurposeofRecords

ProvidingInformationProvidingBasisforQualityReviewProvidingBasisforLegalPurposeProvidingDataforEducationandResearch4精選PurposeofRecordsProvidingPrinciplesofRecords

Timely1ObjectiveandAccurate2Complete3Concise4Legible55精選PrinciplesofRecordsfollowthehospital’srequirementtomakedocumentationatregularintervals.Norecordingshouldbedonebeforeprovidingnursingcares,anddelayingoromittingtherecordingisnotacceptableeither.

Timely16精選followthehospital’srequirem

ObjectiveandAccurate

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

Complete3Leavingnoblanklinesontheclient'schart.thecaregivermustsignhisorherfullnameafterrecording.aclient'sconditioniscritical.aclientinsistsonrefusingatreatmentorleavingthehospitalagainstmedicaladvice.aclienthasinclinationofcommittingsuicide.thesesituationsmustbefilledintheclient'schart.8精選Theclient'sname,age,andbe

Concise4Documentationmustbeconcise,inalogicalorder,andlaystressonkeypoints.9精選ConciseAllentriesmustbelegibleandeasytoread.Whenarecordingerrorismade,drawalinethroughitandwritethecorrector'snameaboveit.Donoterase,blotout,orusecorrectionfluid.

Legible510精選AllentriesmustbelegibleanAdministrationof

MedicalandNursingDocumentsAdministrationRequirementsArrangementOrderofMedicalRecord11精選Administrationof

MedicalandAdministrationRequirements12精選AdministrationRequirements12精Allmedicalandnursingdocumentsshouldbeplacedaccordingtoorganizationguidelines.Theyshouldbereplacedafterbeingreadorrecorded.13精選13精選Medicalandnursingdocumentsmustbekeptneatly,orderly,completelyandpreventthemfrombeingcontaminated,mangled,disconnectedandlost.14精選14精選Theclientortheclient'sfamilyshouldnotreadthemedicalandnursingdocumentsfreely.Nocarryingthedocumentsoutofthewardwithoutbeingpermitted.Ifthedocumentsneedtobecarriedoutofthewardforthepurposeofmedicalactivityorcopy,itshouldbecarriedandkeptwellbyhospitalappointedstaff.15精選15精選Allthedocumentsshouldbekeptproperly.Whentheclientisdischargedfromthehospital,temperaturesheet,physician’sordersheetandspecialnursingrecordchartwillbekeptpermanentlyinMedicalRecordingRoomofthehospitalaspartsoftheclient'scase-notes.Thechange-of-shiftreportwillbekeptatleastoneyearatthewardlevel.16精選16精選ArrangementOrderofMedicalRecordOrderofAdmissionRecordOrderofDischarge(transfer,death)Record17精選ArrangementOrderofMedicalROrderofAdmissionRecordTemperaturesheetPhysician’sordersheetAdmissionsheetandrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsSpecialnursingrecordFirstpageofclientrecordAdmissionsheetOutpatientrecord18精選OrderofAdmissionRecordTempeOrderofDischarge(transfer,death)RecordFirstpageofclientrecordAdmissionsheet(ifclientdied,addingdeathreportsheet)DischargeordeathrecordAdmissionrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsspecialnursingrecordPhysician’sordersheetTemperaturesheet

Outpatientrecordisgivenbacktotheclientortheclient'sfamily.19精選OrderofDischarge(transfer,Section2WritingNursingDocumentsTemperatureSheetManagingPhysician’sOrderRecordingSpecialnursingReportingClient’sConditions20精選Section2WritingNursingDo中國醫(yī)療信息化的發(fā)展

醫(yī)院信息系統(tǒng)(hospitalinformationsystem,HIS)面向臨床工作的醫(yī)院臨床信息系統(tǒng)(clinicalinformationsystem,CIS)將成為HIS的重點發(fā)展方向。CIS包括電子病歷系統(tǒng)、醫(yī)學(xué)影像處理系統(tǒng)、實驗室數(shù)據(jù)處理系統(tǒng)、臨床專科數(shù)據(jù)分析系統(tǒng)等。21精選中國醫(yī)療信息化的發(fā)展醫(yī)院信息系統(tǒng)(hospitalinTemperatureSheetItisonthefirstpageofclient'shospitalizationrecord.itprovidesthestaffwithaquicksummaryofalltheclient'sconditionandvitalsignsonthesheet.22精選TemperatureSheetItisonthe23精選23精選FillinginTopPartThispartmustbefilledinwithablue-blackinkedorcarboninkedpen.Client'sname,sex,age,ward,admissiondateandhospitalizationnumbermustbefilledincompletely.year,monthanddaymustbefilledinthefirstdaycolumnofeverypage.therestsixdayscolumnonly“Day”24精選FillinginTopPartThispartmFillinginBetween40℃~42℃

ColumnofTemperatureSheetTimeofadmission,operation,childbirth,transfer,dischargeordeathisfilledintheverticallineofcorrespondingtimecolumnwitharedinkedpenbetween40℃~42℃column.itisessentialtospecifytheminute.Ifthetimeisnotequaltothetimeattemperaturesheet,fillintheproximaltimecolumn.25精選FillinginBetween40℃~42℃

CoDrawingBodyTemperatureCurveDrawingSphygmogram26精選26精選DrawingBodyTemperatureCurveOraltemperature:“●”，Axillarytemperature

“×，Rectaltemperature

“○”.Twoadjacentreadingsareconnectedbyblueline.27精選DrawingBodyTemperatureCurveAclientwithhyperpyrexianeedstohavethebodytemperaturetakenagaininhalfanhour

afterreceivingphysicaltherapy.Thereadingofmeasuredtemperatureisdrawninthesamelongitudinalcolumnofpreviousreadingbyred“○”,andconnectedwiththereadingbeforephysicaltherapybyreddottedline.Thereadingofnextmeasurementisstillconnectedwiththereadingbeforephysicaltherapy.

28精選Aclientwithhyperpyrexianeeaclient'sbodytemperatureisbelow35℃不升不升Readingofmeasuredtemperatureisrepresentedbyblue“×”,andconnectedwiththe

adjacentreadings.29精選aclient'sbodytemperatureisDrawingSphygmogramPulserateisdrawninred“●”,Twocorrespondingreadingsofpulserateareconnectedbyredline.30精選DrawingSphygmogramPulseratepulsedeficitheartrateisinred“○”.Twocorrespondingreadingsofheartrateareconnectedbyredline.filledintheareabetweenthelineofpulserateandthelineofheartrateinredline.31精選pulsedeficitheartrateisinIfthereadingofbodytemperatureandpulserateareatthesamepoint,drawthetemperaturefirstinblue“×”,thendrawaredcircle(○)outsidetheblue“×”torepresentthepulserate.32精選IfthereadingofbodytemperaRespiration

ReadingsofrespirationarerecordedincorrespondingtimecolumnsinArabicnumberwithbluepenandthenumbersarewrittenalternativelyupwardanddownward.33精選RespirationReadingsofrespirFillinginBottomPart

Allthispartisfilledinbyusingablue-blackinkedorcarboninkedpen.Arabicnumberrepresentsthereadings.Calculationunitisomitted.Contents：34精選FillinginBottomPartBowelMovement

Documentthebowelmovementonthepreviousday.Ifthereisnobowelmovement,document"0";fecalincontinenceisdocumentedas"※";“E”representsenema.(0/E;11/E)Documentthenumberoftimesonceaday1/Erepresentsonetimeofdefecationafterenema.35精選BowelMovementDocumentFluidintakeandoutputDocumentthetotalamountofFluidintakeandoutputofthepreviousday(duringa24-hourperiod)accordingtothephysician'sorder.theamountofintakeandoutputfluidsarerecordedinml.FluidoutputFluidIntake36精選FluidintakeandoutputDocumeBloodPressureIfmoremeasuringisneeded,thereadingsofmeasurementcanberecordedinthenursingnotes.Readingsofbloodpressurearerecordedincorrespondingtimecolumns.110/75,105/7037精選BloodPressureIfmoremeasurinBodyWeightFillitintheunitofkg.Whenaclientisadmitted,thenursemeasureshisorherbodyweightanddocumentsitinthecorrespondingtimecolumn.Duringhospitalization,measureanddocumentbodyweightonceaweek.38精選BodyWeightFillitintheunitdaysofoperation(childbirth)

Thenextdayofoperation(childbirth)isregardedasthefirstdayofoperation(childbirth)thathasbeenchartedcontinuouslyonthedaycolumninArabicnumber“1,2,3...”until10days.Ifasecondoperationhasbeendonewithin10days39精選daysofoperation(childbirth)DaysofhospitalizationwriteinArabicnumber“1,2,3...”fromthedayofadmissiontothedayofdischarge.40精選DaysofhospitalizationwriteiPageNumberFillthepagenumbersinsequence.41精選PageNumberFillthepagenumbeManagingPhysician’sOrderphysicianorderrecordingbook(醫(yī)囑本)

physicianordersheet(醫(yī)囑單)varioustypesofformsthatarenecessaryforimplementation

(各種執(zhí)行單)42精選ManagingPhysician’sOrderphysphysicianorderrecordingbook床號姓名時間醫(yī)囑醫(yī)生執(zhí)行護士簽名時間簽名2007-12-111-3張利8am外科護理常規(guī)馬良李玲Ⅱ級護理流質(zhì)飲食青霉素皮試（）st8am黃華

10%GS500ml

青霉素640萬uivdripqd

丁胺卡那0.2imbidVc100mgtid氧氣吸入prn李玲

2007-12-121-3張利4pm停Vc100mgtid李玲下午2點胸腔穿刺2pm呂新安定5mghs

度冷丁50mgimq6h李玲∨∨∨

醫(yī)囑本山東大學(xué)齊魯醫(yī)院43精選physicianorderrecordingbookphysicianordersheetSTATorderSheetStandingorderSheet44精選physicianordersheetSTATorde45精選45精選varioustypesofforms

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

8pm土霉素0.546精選varioustypesofforms

thataContentsofPhysicianOrderDate,Time,BedNo,Name

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

physician'ssignaturenurse'ssignature47精選ContentsofPhysicianOrderDatTypesofPhysicianOrderStandingOrderSTATOrderPRNOrderSOSOrder48精選TypesofPhysicianOrderStandiStandingOrderAstandingorder

isvaliduntilitiscancelledbythephysician.Usuallythevalidtimeofastandingorderexceeds24hours.49精選StandingOrderAstandingorderSTATOrderThevalidtimelimitofaSTATorder

iswithin24hours,usuallyonlyonce.SometimesaSTAT(ST)ordersignifiesthatasingledoseofmedicationistobegivenimmediately.安定5mghs.50精選STATOrderThevalidtimelimitPRNOrderPRNorderisakindofstandingorder.ThephysicianmayorderatreatmentonaPRNbasisiftheclient'sconditionneeds.Oftenthephysiciansetsminimalintervalsbetweentwotimesofadministration.度冷丁50mgimq6hprn51精選PRNOrderPRNorderisakindoSOSOrderThevalidtimeoftheSOSorderiswithin12hours.Itwillbecarriedoutonlyonceasthestateofanillnessneeds.Itbecomesinvalidifitexceedsthetimelimit.52精選SOSOrderThevalidtimeoftheManagingPhysicianOrder

MethodofHandlingPrinciplesofManaging53精選ManagingPhysicianOrderMethoStandingOrdertransferstheordersontovarioustypesofforms.Thestandingorderstransferredontotheimplementationformswhicharecarriedoutinappointedtimeshouldbesignedspecificadministeredtime.54精選StandingOrdertransferstheoPRNordertransfersthemontovarioustypesofforms.Ifthephysiciansetsminimalintervalsbetweentwotimesofadministration,eachtimethenursecarriesoutthePRNorder,heorshehastodocumenttheexacttimeandsignfullname.55精選PRNordertransfersthemontovSTATOrder“st”meansexecutinganorderimmediately.Aftercarryingouttheorder,thenursehastosignhisorhernamein“executer”columnandnotesthetimeofexecuting.penicillinpositive(＋)negative(－)penicillinskintest56精選STATOrder“st”meansexecutingSOSorderSOSordershouldbecarriedoutonlyonceasthestateofanillnessneeds.Theperson,whocarriesouttheorder,signshisorhernamein“performer”columnandnotesthetimeofexecuting.Theorderbecomesinvalidifitexceedsthetimelimit.Thenursewritestheword“unexecuted”,documentsthetimeandsignshername.57精選SOSorderSOSordershouldbecStoptheOrderIfaphysiciandecidestostopanorderforsomereasons,thenursecancelstheorderinrelatedtreatmentsheetfirst.writedownthedateandtimein“stop”columninphysicianordersheet.58精選StoptheOrderIfaphysiciandRe-arrangingtheOrderdrawaredlinebelowthelastrowofphysicianorders,write“Rearranging”inthemiddlebelowtheredlinewitharedpen,andtranscribeoriginalvalidphysicianordersontospacesbelowtheredline.Twonursesverifytherearrangedordersandsigntheirnames.Aftertheoperation,childbirthortransferring,physicianordershavetoberearrangedtoo.Drawaredlinebelowthelastrowoforiginalorders,andwrite“post-operationorder”,“post-childbirthorder”,59精選Re-arrangingtheOrderdrawarUrgentBeforeRoutine.Whenmanagingseveralphysicianorders,itisnecessarytoseewhichorderismoreimportantorurgenttotheclient,andgivepriorityforcarryingitout.PrinciplesofManaging60精選UrgentBeforeRoutine.PrincipSTATOrderBeforeStandingOrder.

ItisroutinetocarryoutaSTATorderbeforeastandingone.PrinciplesofManaging61精選STATOrderBeforeStandinTheordercouldnotbechanged.Ifitistobecanceled,note“cancel”witharedpenandsign.PrinciplesofManaging62精選TheordercouldnotbechangedGenerallyspeaking,thephysicianshouldnotgiveoralorders.Intheeventsofanemergencyorduringoperationwhenthephysiciangivesordersorallytonurses,thenurseshavetorepeattheorderonceagainandmakesureitiscorrect.Aftertheemergencyhasbeenallayedandthephysicianshouldrecordandsignallordersthatweregiven.PrinciplesofManaging63精選Generallyspeaking,thephysicIfaSTATorSOSorderistobecarriedoutonthenextshift,theordershouldbewrittendowninthenursingnotes.PrinciplesofManaging64精選IfaSTATorSOSorderistobThephysicianordersmustbecheckedineveryshiftandtotallyonceeveryweek.PrinciplesofManaging65精選PrinciplesofManaging65精選clinicalinformationsystem,CIS

醫(yī)囑處理

醫(yī)生登錄醫(yī)生工作站系統(tǒng),將醫(yī)囑按照長期醫(yī)囑、臨時醫(yī)囑、輔助檢查、化驗等分類錄入系統(tǒng),護士登錄護士工作站系統(tǒng)進行處理:審核醫(yī)囑執(zhí)行醫(yī)囑打印表單和醫(yī)囑單66精選clinicalinformationsystem,CRecordingFluidIntakeandOutputContentsMethodsforRecording67精選RecordingFluidIntakeandOutContents出入液量記錄單fluidintakefluidoutputoralfluidintakefoodintakeintravenousfluidinfusions

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

68精選Contents出入液量記錄單fluidintakefl69精選69精選Daytime'sfluidintakeandoutput

arerecordedwithablue-blackinkedorcarboninkedpen;nighttime'sfluidintakeandoutput

arerecordedwitha

redpen.intakeandoutput

aresummarizedattheendofeach12-hourand24-hourperiod.Sum

ofintakeandoutputof24-hourperiodisfilledincorrespondingcolumnofthetemperaturesheet.MethodsforRecording70精選Daytime'sfluidintakeandoutRecordingSpecialNursingContentsofrecordMethodsandRecommendationsforRecording71精選RecordingSpecialNursingConteContentsofrecordvitalsignslevelofconsciousnessfluidintakeandoutputstateofillnessnursinginterventionresponsetomedicationsignature72精選Contentsofrecordvitalsigns7MethodsandRecommendations特別護理記錄單73精選MethodsandRecommendations特別護74精選74精選Change-of-shiftreportComponentsofReportRecommendations

75精選Change-of-shiftreportComponenComponentsofReportDischarge,Transfer-out,andDeathReportAdmission,Transfer-inReportSeverelyIllClients'ReportPostoperativeClients'ReportPre-operation,pre-diagnosticStudiesPreparationReport76精選ComponentsofReportDischarge,TopPart

OrderofWriting

Warddatetimetotalnumberofclients

numberofclientadmission

discharge

transferOperation

childbirth

clientsincriticalstatedeath.discharge,transfer-out,deathadmission,transfer-inoperativeclients,clientswhogivesbirth,criticallyillclients,andclientsofunusualcondition77精選TopPartOrderofWritingWard78精選78精選病人情況日夜報告

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