1、精选1Chapter 16 Nursing Documentation 精选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)精选3Section 1 Record and Administration of medical and Nursing DocumentsPurpose of Rec
2、ords Principle of RecordsAdministration of Medical and Nursing Documents精选4Purpose of Records Providing Information Providing Basis for Quality ReviewProviding Basis for Legal Purpose Providing Data for Education and Research精选5Principles of Records Timely1 Objective and Accurate 2 Complete3 Concise
3、 4 Legible5精选6 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.Timely1精选7 Objective and Accurate 2Recording must be accurate and correct.Accurate rec
4、ordings consist of facts or observations rather than opinions or interpretation.精选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 i
5、s critical.a client 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.精选9 Concise 4Documentation must be concise,in a logical order,and lay stress on key points.精选10 All e
6、ntries must be legible 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.Legible5精选11Administration of Medical and Nursing DocumentsAdministration RequirementsArrangement Order of Medical Record
7、精选12Administration Requirements精选13All medical and nursing documents should be placed according to organization guidelines.They should be replaced after being read or recorded.精选14Medical and nursing documents must be kept neatly,orderly,completely and prevent them from being contaminated,mangled,di
8、sconnected and lost.精选15The 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
9、 kept well by hospital appointed staff.精选16All 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 ca
10、se-notes.The change-of-shift report will be kept at least one year at the ward level.精选17Arrangement Order of Medical RecordOrder of Admission RecordOrder of Discharge(transfer,death)Record精选18Order of Admission Record Temperature sheet Physicians order sheet Admission sheet and record medical histo
11、ry and physical examination Physicians record Consultation record Diagnostic studies reports Special nursing record First page of client record Admission sheet Outpatient record精选19Order of Discharge(transfer,death)Record First page of client record Admission sheet(if client died,adding death report
12、 sheet)Discharge or death record Admission 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.精选20Section
13、2 Writing Nursing DocumentsTemperature SheetManaging Physicians OrderRecording Special nursingReporting Clients Conditions精选21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)面向临床工作的面向临床工作的医院临医院临 床信息系统床信息系统(clinical information system,(clinical infor
14、mation system,CISCIS)将将成为成为HISHIS的重点发展方向。的重点发展方向。CISCIS包括包括电子病电子病历系统历系统、医学影像处理系统、实验室数据、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。精选22Temperature 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 sig
15、ns on the sheet.精选23精选24Filling in Top Part This 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 da
16、ys column only“Day”精选25Filling in Between 4042 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
17、 equal to the time at temperature sheet,fill in the proximal time column.精选26 Drawing Body Temperature CurveDrawing Sphygmogram精选27Drawing Body Temperature Curve Oral temperature:“”，Axillary temperatureAxillary temperature“，Rectal temperatureRectal temperature “”.”.Two adjacent readings are connecte
18、d by Two adjacent readings are connected by blue lineblue line.精选28 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
19、 connected with the reading before physical therapy by red dotted line.The reading of next measurement is still connected with the reading before physical therapy.精选29a clients body temperature is below 35不升不升Reading of measured temperature is represented by blue“”,and connected with the adjacent re
20、adings.精选30Drawing Sphygmogram Pulse rate is drawn in red“”,Two corresponding readings of pulse rate are connected by red line.精选31pulse 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
21、 heart rate in red line.精选32 If the reading of body temperature 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.精选33Respiration Readings of respiration are recorded in corresponding time columns in Arabic
22、 number with blue pen and the numbers are written alternatively upward and downward.精选34Filling 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：精选35Bowel Movement Document the bowel m
23、ovement on the previous day.If there is no bowel movement,document 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.精选36Fluid intake and output Document the total amount of Fluid intake and o
24、utput of the previous day(during a 24-hour period)according to the physicians order.the amount of intake and output fluids are recorded in ml.Fluid outputFluid Intake精选37Blood PressureIf more measuring is needed,the readings of measurement can be recorded in the nursing notes.Readings of blood press
25、ure are recorded in corresponding time columns.110/75,105/70精选38Body Weight 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.精选39days of
26、operation(childbirth)The next day of operation(childbirth)is regarded as the 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 days精选40Days of hospitalizationwrite in Arabic numbe
27、r“1,2,3.”from the day of admission to the day of discharge.精选41Page Number Fill the page numbers in sequence.精选42Managing 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 ty
28、pes of forms that are necessary for implementationnecessary for implementation (各种执行单各种执行单)精选43physician 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 2007-12-12
29、1-3 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 本山东大学齐鲁医院精选44physician order sheetSTAT order SheetStanding order Sheet精选45精选46various types of forms that are necessary for implementation nursing grade sheet diet sheet oral medication sheet injection sheet treatment sheet
30、,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 精选47Contents of Physician Order 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
31、 surgery physicians signature nurses signature精选48Types of Physician Order Standing Order STAT Order PRN Order SOS Order 精选49Standing Order A standing order is valid until it is cancelled by the physician.Usually the valid time of a standing order exceeds 24 hours.精选50STAT Order The valid time limit
32、 of a STAT order is within 24 hours,usually only once.Sometimes a STAT(ST)order signifies that a single dose of medication is to be given immediately.安定 5mg hs.精选51PRN 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
33、the physician sets minimal intervals between two times of administration.度冷丁度冷丁 50mg im q6h prn精选52SOS 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.精选53Managing Physician Ord
34、er Method of HandlingPrinciples of Managing精选54Standing Order transfers the orders onto various types of forms.The standing orders transferred onto the implementation forms which are carried out in appointed time should be signed specific administered time.精选55PRN ordervtransfers them onto various t
35、ypes of forms.vIf the physician sets minimal intervals between two times of administration,each time the nurse carries out the PRN order,he or she has to document the exact time and sign full name.精选56STAT Order“st”means executing an order immediately.After carrying out the order,the nurse has to si
36、gn his or her name in“executer”column and notes the time of executing.penicillin positive()negative()penicillin skin test精选57SOS 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 t
37、he time of executing.The order becomes invalid if it exceeds the time limit.The nurse writes the word“unexecuted”,documents the time and signs her name.精选58Stop 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
38、the date and time in“stop”column in physician order sheet.精选59Re-arranging the Order draw a red line below the last 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 verif
39、y the rearranged orders and sign their names.After the operation,childbirth or transferring,physician orders have to be rearranged too.Draw a red line below the last row of original orders,and write“post-operation order”,“post-childbirth order”,精选60 Urgent Before Routine.When managing several physic
40、ian orders,it is necessary to see which order is more important or urgent to the client,and give priority for carrying it out.Principles of Managing精选61 STAT Order Before Standing Order.It is routine to carry out a STAT order before a standing one.Principles of Managing精选62 The order could not be ch
41、anged.If it is to be canceled,note“cancel”with a red pen and sign.Principles of Managing精选63 Generally speaking,the physician 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
42、and make sure it is correct.After the emergency has been allayed and the physician should record and sign all orders that were given.Principles of Managing精选64 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 Managing精选
43、65 The physician orders must be checked in every shift and totally once every week.Principles of Managing精选66clinical information system,clinical information system,CISCIS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
44、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 精选67Recording Fluid Intake and Output Contents Methods for Recording精选68Contents出入液量记录单fluid intake fluid output oral fluid intakefood intakeintravenous fluid infusions urine,stool,vomit,bleeding,sputum,gastric suction,and drainage from post-surgical drainage tubes.精选69精
45、选70 Daytimes 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.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 correspo
46、nding column of the temperature sheet.Methods for Recording精选71Recording Special Nursing Contents of record Methods and Recommendations for Recording精选72Contents of record vital signs level of consciousness fluid intake and output state of illness nursing intervention response to medication signatur
47、e精选73Methods and Recommendations特别护理记录单精选74精选75Change-of-shift reportComponents of ReportRecommendations 精选76Components of Report Discharge,Transfer-out,and Death Report Admission,Transfer-in Report Severely Ill Clients Report Postoperative Clients Report Pre-operation,pre-diagnostic Studies Prepara
48、tion Report 精选77Top Part Order of Writing Ward date time total number of clients number of clientadmission discharge transfer Operation childbirth clients in critical state death.discharge,transfer-out,death admission,transfer-in operative clients,clients who gives birth,critically ill clients,and c
49、lients of unusual condition 精选78精选79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 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 护士签名精选80Recommendations Record is on the basis of sound observation.Th
50、e report should be concise,accurate and objective,and highlight important points.The report should be neat and legible.Do not erase.Daytimes conditions are recorded with a blue pen,and nighttimes conditions are recorded with a red pen.精选81 Entries are filled in the following orders:write down the be
