护理 英文 护理文件书写ppt课件

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