护理 英文 整理 护理文件书写ppt课件

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Chapter16NursingDocumentation，medicalandnursingdocuments，clientsrecord， aclientsmedicalrecordtemperatureshephysiciansordersheetspecialnusingrecordchart，etc .Change-of-shiftreport . section1recordicandadmicalandnursingdocuments，purpoposefrecords，PrincipleofRecords，admicalandnursingdocuments.purposeofrecords providingdataforeductionandresearch，PrinciplesofRecords， folowthospitalsrequirementtomodocumentationatrularintervals .norecordingshouldbedebeoreproidingnusingcares， anddloringingoromittingtherecordingisnotacceptableeither .recordingmustbeaccurateandccorrect . autratrerecodentsistoffactobserverationsratherthanopinionsorinterpretation .Theclientsname，age， andbednumber shouldbewrittenoneachpageoftherecord .leavingnoblanklineontheclientchart . thecareververustitussishsorherfullnameaferrecording.alcientsconditioniscritical.aliientinsistesonrefusingatreatmentorleavingth cal advice.aliienthasinclinationofcommittingsuicide .thesesstiturationsmustbefilledintheclentschart .Documentationmustbeconcise andlaystressonkeypoints .allentriesmustbelegibreleandeasytoread.whewernarecordingerrorismade， drawalinethroughitandwritethecorrectorsnameaboveit.do not erase，blotout orusecorrectionfluid .admistricationofmedicalandnursing admistricationrequirements，arrangementorderedmedicalrecord， administrationrequirements . allmedicallandnurrnusingdocumentshoulldbepacedftbepacedberentberingdrecordered . medicalandnursingdocumentsmstbekeptneatly，orderly，completelingdpdeventtthemfrombeingecontamidinated，mangled，disconnectedandlost theclitentortheclientsfamillyshouldnotreadthemedicalandlnusingdocumentsfrree.nocarryingthedocumentsoutofftheforwardwithoutbein eedt obecarriedoutoftheforwardforthepurpposeofmedicalactivityorcopy，itshouldbecarriedandeptwellbyhospitallappointedstatff . allthedocumentsshouldbekeptproperly.whentheclientisdischargdforomtheshospital， temperature sheet physiciansordersheetandspeciallnorrsingrecordcharthithehoshitallsherecordicrecolldirecordingroumofthehoshoshii ekeptatleasteyearattheforwardlevel .arrangementorderedmedicalrecord，ordopoptimissisonrecord，orderofdischarge orderedofadmissionrecord temperaturesheetphysiciansordershiteddimissonsheterdrecordmicralisstorandpdisicialingphiciationansree co rtspresspecationlurngrecorrdfirstpageofclientrecordsonshetoutpatientrecord .OrderofDischarge(transfer， death ) record firstpageofclientrecordadmissionsheet (ifclientdied ) addingdeathreportsheet dischargeordeathrecordsadmissonionrecordiclectricalshonddpisicialingphyicansreconsconstationrecontricationdicationscre physicial uresheetoutpatientrecordisgivenbacktotheclientntsfamily .section2writingnursingdocuments， temperature sheet.managing physicians order，recordingrespecificialnusing，reporting clientsconditions，中国医疗信息化的发展，医院信息系统(hospitalinfo ) HIS )面向临床的医院临床信息系统(clinicalinformationsystem，CIS )将成为HIS的重要发展方向。 CIS包括电子病历系统、医学图像处理系统、实验室数据处理系统、临床专业数据分析系统等。. temperature sheet itisonthefirstpageofclientshospilizationrecord.itprovidesshetafwithquicksummaryofallhathestriticonditionandvid ，FillinginTopPart，thispristmustebefilldinwithabue-blackinkdorcarboninkdpen.clients name，sex，age， ward admissiondetandhoshitializationnumbermustebefeverypage .year，monthanddmycustebefedfertheftdacolumnofeverypage .therestsixx filling in between 40 42colnoftemperaturesheet，Timeofadmission，operation，childbirth， transfer dischargeordeathisfillingthevitureconfilentheviternecorrespondingimecolumnihitharedpenbetween 40 42column.itissessentt inute.ifthetimeisnoteq univatttteimattemperaturesheet，fillintheproximaltimecolumn .prodingboditymperturraturrecurredawing prodingboditymperaturre oral temperature : 、Axillarytemperature、rectaltemperature， twoutodeconterationadissereconnectedbyblueeline . alitintwhypryrexienedstohhethehithebodmetratertachinginfarfanhoufferreceiving adingofmeasuredtemperatureisdrawinthesame longitdinalcolumnofpreviousreadingbyred“”andconnectedwiththereadingbeforephysicalthe dingofnexismementsillconnedwiththereadingbeforephysicaltherapy .aclientsbodytempreratureisbelow 35，不上升，不上升， redingofsemationedtemperatersrepresentedbyblue，andconnectedwiththeadjcentradings .DrawingSphygmogram，pulserateisdrawninre twocorresspoingredingsofspleaterateconnedbyredline . pulse deficit heatrateisinred twoocorresposindingredingsoftheratrareeconnectredbyredline.filedintareatebewetheentheneoppera 、ifthereadingofbodytempreratureandpulseserateareatthesamepoint、drawthetemperaturefirstinblue thendrawaredcircle () outsidetheblue“torepresentthepulserate .Respiration， redingsofsofrepiciationarrecorredicnorrespondingimecolumnsinarabicnumberwithblueepennandthenumberrsarewrittenalativelyus FillinginBottomPart，allothispartisfilledbuer-blackinkdorcarboninkedpen.arabicnumberedpentsthereadings.calculationunitisomited 、BowelMovement、documentthemboowelmovementonthepreviousday.ifthereisnobowmovement、document0； fecalicalconntinenceisdocumentedas ； “E”representsenema.(0/E； 11/E )、documentthenumberroftmesonceaday、1/erpressessentityofdefecationafterenema .， fluidintakeandoutput documentthetotalamountofuidintakeandoutfthepreviousday (du