护理-英文-课件-护理文件书写-.ppt

1、1Chapter 16 Nursing Documentation 2medical and nursing documentsclients recordA clients medical recordTemperature sheet Physicians order sheetspecial nursing record chart,etc.Change-of-shift report(病室交班报告病室交班报告)3Section 1 Record and Administration of medical and Nursing DocumentsPurpose of Records P

2、rinciple of RecordsAdministration of Medical and Nursing Documents4Purpose of Records Providing Information Providing Basis for Quality ReviewProviding Basis for Legal Purpose Providing Data for Education and Research5Principles of Records Timely1 Objective and Accurate 2 Complete3 Concise 4 Legible

3、56 follow the hospitals requirement to make documentation at regular intervals.No recording should be done before providing nursing cares,and delaying or omitting the recording is not acceptable either.Timely17 Objective and Accurate 2Recording must be accurate and correct.Accurate recordings consis

4、t of facts or observations rather than opinions or interpretation.8 The clients name,age,and bed number,should be written on each page of the record.Complete3Leaving no blank lines on the clients chart.the caregiver must sign his or her full name after recording.a clients condition is critical.a cli

5、ent insists on refusing a treatment or leaving the hospital against medical advice.a client has inclination of committing suicide.these situations must be filled in the clients chart.910 Concise 4Documentation must be concise,in a logical order,and lay stress on key points.11 All entries must be leg

6、ible and easy to read.When a recording error is made,draw a line through it and write the correctors name above it.Do not erase,blot out,or use correction fluid.Legible512Administration of Medical and Nursing DocumentsAdministration RequirementsArrangement Order of Medical Record13Administration Req

7、uirements14All medical and nursing documents should be placed according to organization guidelines.They should be replaced after being read or recorded.15Medical and nursing documents must be kept neatly,orderly,completely and prevent them from being contaminated,mangled,disconnected and lost.16The

8、client or the clients family should not read the medical and nursing documents freely.No carrying the documents out of the ward without being permitted.If the documents need to be carried out of the ward for the purpose of medical activity or copy,it should be carried and kept well by hospital appoi

9、nted staff.17All the documents should be kept properly.When the client is discharged from the hospital,temperature sheet,physicians order sheet and special nursing record chart will be kept permanently in Medical Recording Room of the hospital as parts of the clients case-notes.The change-of-shift r

10、eport will be kept at least one year at the ward level.18Arrangement Order of Medical RecordOrder of Admission RecordOrder of Discharge(transfer,death)Record19Order of Admission Record Temperature sheet Physicians order sheet Admission sheet and record medical history and physical examination Physic

11、ians record Consultation record Diagnostic studies reports Special nursing record First page of client record Admission sheet Outpatient record20Order of Discharge(transfer,death)Record First page of client record Admission sheet(if client died,adding death report sheet)Discharge or death record Adm

12、ission record medical history and physical examination Physicians record Consultation record Diagnostic studies reports special nursing record Physicians order sheet Temperature sheet Outpatient record is given back to the client or the clients family.21Section 2 Writing Nursing DocumentsTemperature

13、 SheetManaging Physicians OrderRecording Special nursingReporting Clients Conditions22中国医疗信息化的发展中国医疗信息化的发展 医院信息系医院信息系 统统(hospital information(hospital information system,HIS)system,HIS)面向临床工作的医院临面向临床工作的医院临 床信息系统床信息系统(clinical information system,CIS)(clinical information system,CIS)将将成为成为HISHIS的重点发展方

14、向。的重点发展方向。CISCIS包括电子病包括电子病历系统、医学影像处理系统、实验室数据历系统、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。处理系统、临床专科数据分析系统等。23Temperature Sheet It is on the first page of clients hospitalization record.it provides the staff with a quick summary of all the clients condition and vital signs on the sheet.2425Filling in Top Part T

15、his part must be filled in with a blue-black inked or carbon inked pen.Clients name,sex,age,ward,admission date and hospitalization number must be filled in completely.year,month and day must be filled in the first day column of every page.the rest six days column only“Day”26Filling in Between 4042

16、Column of Temperature Sheet Time of admission,operation,childbirth,transfer,discharge or death is filled in the vertical line of corresponding time column with a red inked pen between 40 42 column.it is essential to specify the minute.If the time is not equal to the time at temperature sheet,fill in

17、 the proximal time column.27 Drawing Body Temperature CurveDrawing Sphygmogram28Drawing Body Temperature Curve Oral temperature:“”，Axillary temperatureAxillary temperature“，Rectal temperature Rectal temperature“”.”.Two adjacent readings are connected by blue line.Two adjacent readings are connected

18、by blue line.29 A client with hyperpyrexia needs to have the body temperature taken again in half an hour after receiving physical therapy.The reading of measured temperature is drawn in the same longitudinal column of previous reading by red“”,and connected with the reading before physical therapy

19、by red dotted line.The reading of next measurement is still connected with the reading before physical therapy.30a clients body temperature is below 35不升不升Reading of measured temperature is represented by blue“”,and connected with the adjacent readings.31Drawing Sphygmogram Pulse rate is drawn in re

20、d“”,Two corresponding readings of pulse rate are connected by red line.32pulse deficit heart rate is in red“”.Two corresponding readings of heart rate are connected by red line.filled in the area between the line of pulse rate and the line of heart rate in red line.33 If the reading of body temperat

21、ure and pulse rate are at the same point,draw the temperature first in blue“”,then draw a red circle()outside the blue“”to represent the pulse rate.34Respiration Readings of respiration are recorded in corresponding time columns in Arabic number with blue pen and the numbers are written alternativel

22、y upward and downward.35Filling in Bottom Part All this part is filled in by using a blue-black inked or carbon inked pen.Arabic number represents the readings.Calculation unit is omitted.Contents：36Bowel Movement Document the bowel movement on the previous day.If there is no bowel movement,document

23、 0;fecal incontinence is documented as;“E”represents enema.(0/E;11/E)Document the number of times once a day 1/E represents one time of defecation after enema.37Fluid intake and output Document the total amount of Fluid intake and output of the previous day(during a 24-hour period)according to the p

24、hysicians order.the amount of intake and output fluids are recorded in ml.Fluid outputFluid Intake38Blood PressureIf more measuring is needed,the readings of measurement can be recorded in the nursing notes.Readings of blood pressure are recorded in corresponding time columns.110/75,105/7039Body Wei

25、ght Fill it in the unit of kg.When a client is admitted,the nurse measures his or her body weight and documents it in the corresponding time column.During hospitalization,measure and document body weight once a week.40days of operation(childbirth)The next day of operation(childbirth)is regarded as t

26、he first day of operation(childbirth)that has been charted continuously on the day column in Arabic number“1,2,3.”until 10 days.If a second operation has been done within 10 days41Days of hospitalizationwrite in Arabic number“1,2,3.”from the day of admission to the day of discharge.42Page Number Fil

27、l the page numbers in sequence.43Managing Physicians Orderphysician order recording book(physician order recording book(医嘱本医嘱本)physician order sheet(physician order sheet(医嘱单医嘱单)various types of forms that are various types of forms that are necessary for implementation necessary for implementation(

28、各种执行单各种执行单)44physician order recording book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 级护理 流质饮食 青霉素皮试（）st 8am 黄华 10%GS500ml 青霉素640万u ivdrip qd 丁 胺卡那 0.2 im bid Vc 100mg tid 氧气吸入 p r n 李玲 2007-12-121-3 张利 4pm 停Vc 100mg tid 李玲 下午2点胸腔穿刺 2pm 吕新 安定 5mg hs 度冷丁 50mg im q6h 李玲 医 嘱 本山东大学

29、齐鲁医院45physician order sheetSTAT order SheetStanding order Sheet4647various types of forms that are necessary for implementation nursing grade sheet diet sheet oral medication sheet injection sheet treatment sheet,etc.口服药口服药1-3 张利张利8 12 4Vc 100mg土霉素土霉素 0.5 8pm 土霉素土霉素 0.5 48Contents of Physician Order

30、 Date,Time,Bed No,Name routine care grade of nursing diet body position medication(name,dosage,routes of administration);pre-operation preparation;diagnostic Study and therapy,preparation for diagnostic test or surgery physicians signature nurses signature49Types of Physician Order Standing Order ST

31、AT Order PRN Order SOS Order 50Standing Order A standing order is valid until it is cancelled by the physician.Usually the valid time of a standing order exceeds 24 hours.51STAT Order The valid time limit of a STAT order is within 24 hours,usually only once.Sometimes a STAT(ST)order signifies that a

32、 single dose of medication is to be given immediately.安定 5mg hs.52PRN Order PRN order is a kind of standing order.The physician may order a treatment on a PRN basis if the clients condition needs.Often the physician sets minimal intervals between two times of administration.度冷丁度冷丁 50mg im q6h prn53S

33、OS 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 time limit.54Managing Physician Order Method of HandlingPrinciples of Managing55Standing Order transfers the orders onto various types of

34、 forms.The standing orders transferred onto the implementation forms which are carried out in appointed time should be signed specific administered time.56PRN ordervtransfers them onto various types of forms.vIf the physician sets minimal intervals between two times of administration,each time the n

35、urse carries out the PRN order,he or she has to document the exact time and sign full name.57STAT Order“st”means executing an order immediately.After carrying out the order,the nurse has to sign his or her name in“executer”column and notes the time of executing.penicillin positive()negative()penicil

36、lin skin test58SOS order SOS order should be carried out only once as the state of an illness needs.The person,who carries out the order,signs his or her name in“performer”column and notes the time of executing.The order becomes invalid if it exceeds the time limit.The nurse writes the word“unexecut

37、ed”,documents the time and signs her name.59Stop the Order If a physician decides to stop an order for some reasons,the nurse cancels the order in related treatment sheet first.write down the date and time in“stop”column in physician order sheet.60Re-arranging the Order draw a red line below the las

38、t row of physician orders,write“Rearranging”in the middle below the red line with a red pen,and transcribe original valid physician orders onto spaces below the red line.Two nurses verify the rearranged orders and sign their names.After the operation,childbirth or transferring,physician orders have

39、to be rearranged too.Draw a red line below the last row of original orders,and write“post-operation order”,“post-childbirth order”,61 Urgent Before Routine.When managing several physician orders,it is necessary to see which order is more important or urgent to the client,and give priority for carryi

40、ng it out.Principles of Managing62 STAT Order Before Standing Order.It is routine to carry out a STAT order before a standing one.Principles of Managing63 The order could not be changed.If it is to be canceled,note“cancel”with a red pen and sign.Principles of Managing64 Generally speaking,the physic

41、ian should not give oral orders.In the events of an emergency or during operation when the physician gives orders orally to nurses,the nurses have to repeat the order once again and make sure it is correct.After the emergency has been allayed and the physician should record and sign all orders that

42、were given.Principles of Managing65 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 Managing66 The physician orders must be checked in every shift and totally once every week.Principles of Managing67clinical informatio

43、n system,CISclinical information system,CIS医嘱处理医嘱处理 医生登录医生工作站系统医生登录医生工作站系统,将医嘱按照长期医嘱、将医嘱按照长期医嘱、临时医嘱、辅助检查、化验等分类临时医嘱、辅助检查、化验等分类 录入系统录入系统,护士护士登录护士工作站系统进行处理登录护士工作站系统进行处理:审核医嘱审核医嘱 执行医嘱执行医嘱 打印表单和医嘱单打印表单和医嘱单 68Recording Fluid Intake and Output Contents Methods for Recording69Contents出入液量记录单fluid intake flu

44、id output oral fluid intakefood intakeintravenous fluid infusions urine,stool,vomit,bleeding,sputum,gastric suction,and drainage from post-surgical drainage tubes.7071 Daytimes fluid intake and output are recorded with a blue-black inked or carbon inked pen;nighttimes fluid intake and output are rec

45、orded with a red pen.intake and output are summarized at the end of 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.Methods for Recording72Recording Special Nursing Contents of record Methods and Recommendations fo

46、r Recording73Contents of record vital signs level of consciousness fluid intake and output state of illness nursing intervention response to medication signature74Methods and Recommendations特别护理记录单7576Change-of-shift reportComponents of ReportRecommendations 77Components of Report Discharge,Transfer

47、-out,and Death Report Admission,Transfer-in Report Severely Ill Clients Report Postoperative Clients Report Pre-operation,pre-diagnostic Studies Preparation Report 78Top Part Order of Writing Ward date time total number of clients number of clientadmission discharge transfer Operation childbirth cli

48、ents in critical state death.discharge,transfer-out,death admission,transfer-in operative clients,clients who gives birth,critically ill clients,and clients of unusual condition 7980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 T P R at 4pm T P R

49、 at T P R at 庞月 患者 患者 患者上消化道穿孔并腹膜炎 新 31床 T P R at 吴军 肺癌 手术 护理要点：1、护士签名 护士签名 护士签名81Recommendations Record is on the basis of sound observation.The report should be concise,accurate and objective,and highlight important points.The report should be neat and legible.Do not erase.Daytimes conditions are

50、recorded with a blue pen,and nighttimes conditions are recorded with a red pen.82 Entries are filled in the following orders:write down the bed numbername and diagnosis vital signs and the time of measuringthe clients conditions,treatment and nursing care provided83 For clients newly admitted,transf