护理 英文 完整 护理文件书写ppt课件

精选,1,Chapter16NursingDocumentation,精选,2,medicalandnursingdocuments,clientsrecord,AclientsmedicalrecordTemperaturesheetPhysiciansordersheetspecialnursingrecordchart,etc.,Change-of-shiftreport(病室交班报告),精选,3,Section1RecordandAdministrationofmedicalandNursingDocuments,PurposeofRecords,PrincipleofRecords,AdministrationofMedicalandNursingDocuments,精选,4,PurposeofRecords,ProvidingDataforEducationandResearch,精选,5,PrinciplesofRecords,精选,6,followthehospitalsrequirementtomakedocumentationatregularintervals.,Norecordingshouldbedonebeforeprovidingnursingcares,anddelayingoromittingtherecordingisnotacceptableeither.,精选,7,Recordingmustbeaccurateandcorrect.,Accuraterecordingsconsistoffactsorobservationsratherthanopinionsorinterpretation.,精选,8,Theclientsname,age,andbednumber,shouldbewrittenoneachpageoftherecord.,Leavingnoblanklinesontheclientschart.,thecaregivermustsignhisorherfullnameafterrecording.,aclientsconditioniscritical.aclientinsistsonrefusingatreatmentorleavingthehospitalagainstmedicaladvice.aclienthasinclinationofcommittingsuicide.,thesesituationsmustbefilledintheclientschart.,精选,9,Documentationmustbeconcise,inalogicalorder,andlaystressonkeypoints.,精选,10,Allentriesmustbelegibleandeasytoread.Whenarecordingerrorismade,drawalinethroughitandwritethecorrectorsnameaboveit.Donoterase,blotout,orusecorrectionfluid.,精选,11,AdministrationofMedicalandNursingDocuments,AdministrationRequirements,ArrangementOrderofMedicalRecord,精选,12,AdministrationRequirements,精选,13,Allmedicalandnursingdocumentsshouldbeplacedaccordingtoorganizationguidelines.Theyshouldbereplacedafterbeingreadorrecorded.,精选,14,Medicalandnursingdocumentsmustbekeptneatly,orderly,completelyandpreventthemfrombeingcontaminated,mangled,disconnectedandlost.,精选,15,Theclientortheclientsfamilyshouldnotreadthemedicalandnursingdocumentsfreely.Nocarryingthedocumentsoutofthewardwithoutbeingpermitted.Ifthedocumentsneedtobecarriedoutofthewardforthepurposeofmedicalactivityorcopy,itshouldbecarriedandkeptwellbyhospitalappointedstaff.,精选,16,Allthedocumentsshouldbekeptproperly.Whentheclientisdischargedfromthehospital,temperaturesheet,physiciansordersheetandspecialnursingrecordchartwillbekeptpermanentlyinMedicalRecordingRoomofthehospitalaspartsoftheclientscase-notes.Thechange-of-shiftreportwillbekeptatleastoneyearatthewardlevel.,精选,17,ArrangementOrderofMedicalRecord,OrderofAdmissionRecord,OrderofDischarge(transfer,death)Record,精选,18,OrderofAdmissionRecord,TemperaturesheetPhysiciansordersheetAdmissionsheetandrecordmedicalhistoryandphysicalexaminationPhysiciansrecordConsultationrecordDiagnosticstudiesreportsSpecialnursingrecordFirstpageofclientrecordAdmissionsheetOutpatientrecord,精选,19,OrderofDischarge(transfer,death)Record,FirstpageofclientrecordAdmissionsheet(ifclientdied,addingdeathreportsheet)DischargeordeathrecordAdmissionrecordmedicalhistoryandphysicalexaminationPhysiciansrecordConsultationrecordDiagnosticstudiesreportsspecialnursingrecordPhysiciansordersheetTemperaturesheetOutpatientrecordisgivenbacktotheclientortheclientsfamily.,精选,20,Section2WritingNursingDocuments,TemperatureSheet,ManagingPhysiciansOrder,RecordingSpecialnursing,ReportingClientsConditions,精选,21,中国医疗信息化的发展,医院信息系统(hospitalinformationsystem,HIS)面向临床工作的医院临床信息系统(clinicalinformationsystem,CIS)将成为HIS的重点发展方向。CIS包括电子病历系统、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。,精选,22,TemperatureSheet,Itisonthefirstpageofclientshospitalizationrecord.itprovidesthestaffwithaquicksummaryofalltheclientsconditionandvitalsignsonthesheet.,精选,23,精选,24,FillinginTopPart,Thispartmustbefilledinwithablue-blackinkedorcarboninkedpen.Clientsname,sex,age,ward,admissiondateandhospitalizationnumbermustbefilledincompletely.,year,monthanddaymustbefilledinthefirstdaycolumnofeverypage.,therestsixdayscolumnonly“Day”,精选,25,FillinginBetween4042ColumnofTemperatureSheet,Timeofadmission,operation,childbirth,transfer,dischargeordeathisfilledintheverticallineofcorrespondingtimecolumnwitharedinkedpenbetween4042column.itisessentialtospecifytheminute.Ifthetimeisnotequaltothetimeattemperaturesheet,fillintheproximaltimecolumn.,精选,26,DrawingBodyTemperatureCurveDrawingSphygmogram,精选,27,DrawingBodyTemperatureCurve,Oraltemperature:“”，Axillarytemperature“，Rectaltemperature“”.Twoadjacentreadingsareconnectedbyblueline.,精选,28,Aclientwithhyperpyrexianeedstohavethebodytemperaturetakenagaininhalfanhourafterreceivingphysicaltherapy.Thereadingofmeasuredtemperatureisdrawninthesamelongitudinalcolumnofpreviousreadingbyred“”,andconnectedwiththereadingbeforephysicaltherapybyreddottedline.Thereadingofnextmeasurementisstillconnectedwiththereadingbeforephysicaltherapy.,精选,29,aclientsbodytemperatureisbelow35,不升,不升,Readingofmeasuredtemperatureisrepresentedbyblue“”,andconnectedwiththeadjacentreadings.,精选,30,DrawingSphygmogram,Pulserateisdrawninred“”,Twocorrespondingreadingsofpulserateareconnectedbyredline.,精选,31,pulsedeficit,heartrateisinred“”.Twocorrespondingreadingsofheartrateareconnectedbyredline.filledintheareabetweenthelineofpulserateandthelineofheartrateinredline.,精选,32,Ifthereadingofbodytemperatureandpulserateareatthesamepoint,drawthetemperaturefirstinblue“”,thendrawaredcircle()outsidetheblue“”torepresentthepulserate.,精选,33,Respiration,ReadingsofrespirationarerecordedincorrespondingtimecolumnsinArabicnumberwithbluepenandthenumbersarewrittenalternativelyupwardanddownward.,精选,34,FillinginBottomPart,Allthispartisfilledinbyusingablue-blackinkedorcarboninkedpen.Arabicnumberrepresentsthereadings.Calculationunitisomitted.Contents：,精选,35,BowelMovement,Documentthebowelmovementonthepreviousday.Ifthereisnobowelmovement,document0;fecalincontinenceisdocumentedas;“E”representsenema.(0/E;11/E),Documentthenumberoftimesonceaday,1/Erepresentsonetimeofdefecationafterenema.,精选,36,Fluidintakeandoutput,DocumentthetotalamountofFluidintakeandoutputofthepreviousday(duringa24-hourperiod)accordingtothephysiciansorder.theamountofintakeandoutputfluidsarerecordedinml.,Fluidoutput,FluidIntake,精选,37,BloodPressure,Ifmoremeasuringisneeded,thereadingsofmeasurementcanberecordedinthenursingnotes.,Readingsofbloodpressurearerecordedincorrespondingtimecolumns.,110/75,105/70,精选,38,BodyWeight,Fillitintheunitofkg.Whenaclientisadmitted,thenursemeasureshisorherbodyweightanddocumentsitinthecorrespondingtimecolumn.Duringhospitalization,measureanddocumentbodyweightonceaweek.,精选,39,daysofoperation(childbirth),Thenextdayofoperation(childbirth)isregardedasthefirstdayofoperation(childbirth)thathasbeenchartedcontinuouslyonthedaycolumninArabicnumber“1,2,3.”until10days.,Ifasecondoperationhasbeendonewithin10days,精选,40,Daysofhospitalization,writeinArabicnumber“1,2,3.”fromthedayofadmissiontothedayofdischarge.,精选,41,PageNumber,Fillthepagenumbersinsequence.,精选,42,ManagingPhysiciansOrder,physicianorderrecordingbook(医嘱本),physicianordersheet(医嘱单),varioustypesofformsthatarenecessaryforimplementation(各种执行单),精选,43,physicianorderrecordingbook,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（）st8am黄华10%GS500ml青霉素640万uivdripqd丁胺卡那0.2imbidVc100mgtid氧气吸入prn李玲2007-12-121-3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,精选,44,physicianordersheet,STATorderSheet,StandingorderSheet,精选,45,精选,46,varioustypesofformsthatarenecessaryforimplementation,nursinggradesheetdietsheetoralmedicationsheetinjectionsheettreatmentsheet,etc.,口服药1-3张利8124Vc100mg土霉素0.58pm土霉素0.5,精选,47,ContentsofPhysicianOrder,Date,Time,BedNo,Name,routinecaregradeofnursingdietbodyposition,medication(name,dosage,routesofadministration);pre-operationpreparation;diagnosticStudyandtherapy,preparationfordiagnostictestorsurgery,physicianssignaturenursessignature,精选,48,TypesofPhysicianOrder,StandingOrderSTATOrderPRNOrderSOSOrder,精选,49,StandingOrder,Astandingorderisvaliduntilitiscancelledbythephysician.Usuallythevalidtimeofastandingorderexceeds24hours.,精选,50,STATOrder,ThevalidtimelimitofaSTATorderiswithin24hours,usuallyonlyonce.SometimesaSTAT(ST)ordersignifiesthatasingledoseofmedicationistobegivenimmediately.,安定5mghs.,精选,51,PRNOrder,PRNorderisakindofstandingorder.ThephysicianmayorderatreatmentonaPRNbasisiftheclientsconditionneeds.Oftenthephysiciansetsminimalintervalsbetweentwotimesofadministration.,度冷丁50mgimq6hprn,精选,52,SOSOrder,ThevalidtimeoftheSOSorderiswithin12hours.Itwillbecarriedoutonlyonceasthestateofanillnessneeds.Itbecomesinvalidifitexceedsthetimelimit.,精选,53,ManagingPhysicianOrder,MethodofHandling,PrinciplesofManaging,精选,54,StandingOrder,transferstheordersontovarioustypesofforms.Thestandingorderstransferredontotheimplementationformswhicharecarriedoutinappointedtimeshouldbesignedspecificadministeredtime.,精选,55,PRNorder,transfersthemontovarioustypesofforms.Ifthephysiciansetsminimalintervalsbetweentwotimesofadministration,eachtimethenursecarriesoutthePRNorder,heorshehastodocumenttheexacttimeandsignfullname.,精选,56,STATOrder,“st”meansexecutinganorderimmediately.Aftercarryingouttheorder,thenursehastosignhisorhernamein“executer”columnandnotesthetimeofexecuting.,penicillinpositive()negative(),penicillinskintest,精选,57,SOSorder,SOSordershouldbecarriedoutonlyonceasthestateofanillnessneeds.Theperson,whocarriesouttheorder,signshisorhernamein“performer”columnandnotesthetimeofexecuting.Theorderbecomesinvalidifitexceedsthetimelimit.Thenursewritestheword“unexecuted”,documentsthetimeandsignshername.,精选,58,StoptheOrder,Ifaphysiciandecidestostopanorderforsomereasons,thenursecancelstheorderinrelatedtreatmentsheetfirst.writedownthedateandtimein“stop”columninphysicianordersheet.,精选,59,Re-arrangingtheOrder,drawaredlinebelowthelastrowofphysicianorders,write“Rearranging”inthemiddlebelowtheredlinewitharedpen,andtranscribeoriginalvalidphysicianordersontospacesbelowtheredline.Twonursesverifytherearrangedordersandsigntheirnames.Aftertheoperation,childbirthortransferring,physicianordershavetoberearrangedtoo.Drawaredlinebelowthelastrowoforiginalorders,andwrite“post-operationorder”,“post-childbirthorder”,精选,60,UrgentBeforeRoutine.Whenmanagingseveralphysicianorders,itisnecessarytoseewhichorderismoreimportantorurgenttotheclient,andgivepriorityforcarryingitout.,PrinciplesofManaging,精选,61,STATOrderBeforeStandingOrder.ItisroutinetocarryoutaSTATorderbeforeastandingone.,PrinciplesofManaging,精选,62,Theordercouldnotbechanged.Ifitistobecanceled,note“cancel”witharedpenandsign.,PrinciplesofManaging,精选,63,Generallyspeaking,thephysicianshouldnotgiveoralorders.Intheeventsofanemergencyorduringoperationwhenthephysiciangivesordersorallytonurses,thenurseshavetorepeattheorderonceagainandmakesureitiscorrect.Aftertheemergencyhasbeenallayedandthephysicianshouldrecordandsignallordersthatweregiven.,PrinciplesofManaging,精选,64,IfaSTATorSOSorderistobecarriedoutonthenextshift,theordershouldbewrittendowninthenursingnotes.,PrinciplesofManaging,精选,65,Thephysicianordersmustbecheckedineveryshiftandtotallyonceeveryweek.,PrinciplesofManaging,精选,66,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,精选,67,RecordingFluidIntakeandOutput,Contents,MethodsforRecording,精选,68,Contents,出入液量记录单,fluidintake,fluidoutput,oralfluidintakefoodintakeintravenousfluidinfusions,urine,stool,vomit,bleeding,sputum,gastricsuction,anddrainagefrompost-surgicaldrainagetubes.,精选,69,精选,70,Daytimesfluidintakeandoutputarerecordedwithablue-blackinkedorcarboninkedpen;akeandoutputaresummarizedattheendofeach12-hourand24-hourperiod.Sumofintakeandoutputof24-hourperiodisfilledincorrespondingcolumnofthetemperaturesheet.,MethodsforRecording,精选,71,RecordingSpecialNursing,Contentsofrecord,MethodsandRecommendationsforRecording,精选,72,Contentsofrecord,vitalsignslevelofconsciousnessfluidintakeandoutputstateofillnessnursinginterventionresponsetomedicationsignature,精选,73,MethodsandRecommendations,特别护理记录单,精选,74,精选,75,Change-of-shiftreport,ComponentsofReport,Recommendations,精选,76,ComponentsofReport,Discharge,Transfer-out,andDeathReportAdmission,Transfer-inReportSeverelyIllClientsReportPostoperativeClientsReportPre-operation,pre-diagnosticStudiesPreparationReport,精选,77,TopPart,Orde