护理 英文护理文件书写

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