护理-英文-完整-护理文件书写课件

Chapter16

NursingDocumentation

1精选Chapter16

NursingDocumentmedicalandnursingdocumentsclient'srecordAclient'smedicalrecordTemperaturesheetPhysician’sordersheetspecialnursingrecordchart,etc.Change-of-shiftreport(病室交班报告)

2精选medicalandnursingdocumentscSection1RecordandAdministration

ofmedicalandNursingDocumentsPurposeofRecordsPrincipleofRecordsAdministrationofMedicalandNursingDocuments3精选Section1RecordandAdminPurposeofRecords

ProvidingInformationProvidingBasisforQualityReviewProvidingBasisforLegalPurposeProvidingDataforEducationandResearch4精选PurposeofRecordsProvidingPrinciplesofRecords

Timely1ObjectiveandAccurate2Complete3Concise4Legible55精选PrinciplesofRecordsfollowthehospital’srequirementtomakedocumentationatregularintervals.Norecordingshouldbedonebeforeprovidingnursingcares,anddelayingoromittingtherecordingisnotacceptableeither.

Timely16精选followthehospital’srequirem

ObjectiveandAccurate

2Recordingmustbeaccurateandcorrect.Accuraterecordingsconsistoffactsorobservationsratherthanopinionsorinterpretation.7精选ObjectiveandAccurate2RecoTheclient'sname,age,andbednumber,shouldbewrittenoneachpageoftherecord.

Complete3Leavingnoblanklinesontheclient'schart.thecaregivermustsignhisorherfullnameafterrecording.aclient'sconditioniscritical.aclientinsistsonrefusingatreatmentorleavingthehospitalagainstmedicaladvice.aclienthasinclinationofcommittingsuicide.thesesituationsmustbefilledintheclient'schart.8精选Theclient'sname,age,andbe

Concise4Documentationmustbeconcise,inalogicalorder,andlaystressonkeypoints.9精选ConciseAllentriesmustbelegibleandeasytoread.Whenarecordingerrorismade,drawalinethroughitandwritethecorrector'snameaboveit.Donoterase,blotout,orusecorrectionfluid.

Legible510精选AllentriesmustbelegibleanAdministrationof

MedicalandNursingDocumentsAdministrationRequirementsArrangementOrderofMedicalRecord11精选Administrationof

MedicalandAdministrationRequirements12精选AdministrationRequirements12精Allmedicalandnursingdocumentsshouldbeplacedaccordingtoorganizationguidelines.Theyshouldbereplacedafterbeingreadorrecorded.13精选13精选Medicalandnursingdocumentsmustbekeptneatly,orderly,completelyandpreventthemfrombeingcontaminated,mangled,disconnectedandlost.14精选14精选Theclientortheclient'sfamilyshouldnotreadthemedicalandnursingdocumentsfreely.Nocarryingthedocumentsoutofthewardwithoutbeingpermitted.Ifthedocumentsneedtobecarriedoutofthewardforthepurposeofmedicalactivityorcopy,itshouldbecarriedandkeptwellbyhospitalappointedstaff.15精选15精选Allthedocumentsshouldbekeptproperly.Whentheclientisdischargedfromthehospital,temperaturesheet,physician’sordersheetandspecialnursingrecordchartwillbekeptpermanentlyinMedicalRecordingRoomofthehospitalaspartsoftheclient'scase-notes.Thechange-of-shiftreportwillbekeptatleastoneyearatthewardlevel.16精选16精选ArrangementOrderofMedicalRecordOrderofAdmissionRecordOrderofDischarge(transfer,death)Record17精选ArrangementOrderofMedicalROrderofAdmissionRecordTemperaturesheetPhysician’sordersheetAdmissionsheetandrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsSpecialnursingrecordFirstpageofclientrecordAdmissionsheetOutpatientrecord18精选OrderofAdmissionRecordTempeOrderofDischarge(transfer,death)RecordFirstpageofclientrecordAdmissionsheet(ifclientdied,addingdeathreportsheet)DischargeordeathrecordAdmissionrecordmedicalhistoryandphysicalexaminationPhysician'srecordConsultationrecordDiagnosticstudiesreportsspecialnursingrecordPhysician’sordersheetTemperaturesheet

Outpatientrecordisgivenbacktotheclientortheclient'sfamily.19精选OrderofDischarge(transfer,Section2WritingNursingDocumentsTemperatureSheetManagingPhysician’sOrderRecordingSpecialnursingReportingClient’sConditions20精选Section2WritingNursingDo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精选中国医疗信息化的发展医院信息系统(hospitalinTemperatureSheetItisonthefirstpageofclient'shospitalizationrecord.itprovidesthestaffwithaquicksummaryofalltheclient'sconditionandvitalsignsonthesheet.22精选TemperatureSheetItisonthe23精选23精选FillinginTopPartThispartmustbefilledinwithablue-blackinkedorcarboninkedpen.Client'sname,sex,age,ward,admissiondateandhospitalizationnumbermustbefilledincompletely.year,monthanddaymustbefilledinthefirstdaycolumnofeverypage.therestsixdayscolumnonly“Day”24精选FillinginTopPartThispartmFillinginBetween40℃~42℃

ColumnofTemperatureSheetTimeofadmission,operation,childbirth,transfer,dischargeordeathisfilledintheverticallineofcorrespondingtimecolumnwitharedinkedpenbetween40℃~42℃column.itisessentialtospecifytheminute.Ifthetimeisnotequaltothetimeattemperaturesheet,fillintheproximaltimecolumn.25精选FillinginBetween40℃~42℃

CoDrawingBodyTemperatureCurveDrawingSphygmogram26精选26精选DrawingBodyTemperatureCurveOraltemperature:“●”，Axillarytemperature

“×，Rectaltemperature

“○”.Twoadjacentreadingsareconnectedbyblueline.27精选DrawingBodyTemperatureCurveAclientwithhyperpyrexianeedstohavethebodytemperaturetakenagaininhalfanhour

afterreceivingphysicaltherapy.Thereadingofmeasuredtemperatureisdrawninthesamelongitudinalcolumnofpreviousreadingbyred“○”,andconnectedwiththereadingbeforephysicaltherapybyreddottedline.Thereadingofnextmeasurementisstillconnectedwiththereadingbeforephysicaltherapy.

28精选Aclientwithhyperpyrexianeeaclient'sbodytemperatureisbelow35℃不升不升Readingofmeasuredtemperatureisrepresentedbyblue“×”,andconnectedwiththe

adjacentreadings.29精选aclient'sbodytemperatureisDrawingSphygmogramPulserateisdrawninred“●”,Twocorrespondingreadingsofpulserateareconnectedbyredline.30精选DrawingSphygmogramPulseratepulsedeficitheartrateisinred“○”.Twocorrespondingreadingsofheartrateareconnectedbyredline.filledintheareabetweenthelineofpulserateandthelineofheartrateinredline.31精选pulsedeficitheartrateisinIfthereadingofbodytemperatureandpulserateareatthesamepoint,drawthetemperaturefirstinblue“×”,thendrawaredcircle(○)outsidetheblue“×”torepresentthepulserate.32精选IfthereadingofbodytemperaRespiration

ReadingsofrespirationarerecordedincorrespondingtimecolumnsinArabicnumberwithbluepenandthenumbersarewrittenalternativelyupwardanddownward.33精选RespirationReadingsofrespirFillinginBottomPart

Allthispartisfilledinbyusingablue-blackinkedorcarboninkedpen.Arabicnumberrepresentsthereadings.Calculationunitisomitted.Contents：34精选FillinginBottomPartBowelMovement

Documentthebowelmovementonthepreviousday.Ifthereisnobowelmovement,document"0";fecalincontinenceisdocumentedas"※";“E”representsenema.(0/E;11/E)Documentthenumberoftimesonceaday1/Erepresentsonetimeofdefecationafterenema.35精选BowelMovementDocumentFluidintakeandoutputDocumentthetotalamountofFluidintakeandoutputofthepreviousday(duringa24-hourperiod)accordingtothephysician'sorder.theamountofintakeandoutputfluidsarerecordedinml.FluidoutputFluidIntake36精选FluidintakeandoutputDocumeBloodPressureIfmoremeasuringisneeded,thereadingsofmeasurementcanberecordedinthenursingnotes.Readingsofbloodpressurearerecordedincorrespondingtimecolumns.110/75,105/7037精选BloodPressureIfmoremeasurinBodyWeightFillitintheunitofkg.Whenaclientisadmitted,thenursemeasureshisorherbodyweightanddocumentsitinthecorrespondingtimecolumn.Duringhospitalization,measureanddocumentbodyweightonceaweek.38精选BodyWeightFillitintheunitdaysofoperation(childbirth)

Thenextdayofoperation(childbirth)isregardedasthefirstdayofoperation(childbirth)thathasbeenchartedcontinuouslyonthedaycolumninArabicnumber“1,2,3...”until10days.Ifasecondoperationhasbeendonewithin10days39精选daysofoperation(childbirth)DaysofhospitalizationwriteinArabicnumber“1,2,3...”fromthedayofadmissiontothedayofdischarge.40精选DaysofhospitalizationwriteiPageNumberFillthepagenumbersinsequence.41精选PageNumberFillthepagenumbeManagingPhysician’sOrderphysicianorderrecordingbook(医嘱本)

physicianordersheet(医嘱单)varioustypesofformsthatarenecessaryforimplementation

(各种执行单)42精选ManagingPhysician’sOrderphysphysicianorderrecordingbook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Ⅱ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精选physicianorderrecordingbookphysicianordersheetSTATorderSheetStandingorderSheet44精选physicianordersheetSTATorde45精选45精选varioustypesofforms

thatarenecessaryforimplementationnursinggradesheetdietsheetoralmedicationsheetinjectionsheettreatmentsheet,etc.口服药1-3张利8–12–4Vc100mg土霉素0.5

8pm土霉素0.546精选varioustypesofforms

thataContentsofPhysicianOrderDate,Time,BedNo,Name

routinecaregradeofnursingdietbodypositionmedication(name,dosage,routesofadministration);pre-operationpreparation;diagnosticStudyandtherapy,preparationfordiagnostictestorsurgery

physician'ssignaturenurse'ssignature47精选ContentsofPhysicianOrderDatTypesofPhysicianOrderStandingOrderSTATOrderPRNOrderSOSOrder48精选TypesofPhysicianOrderStandiStandingOrderAstandingorder

isvaliduntilitiscancelledbythephysician.Usuallythevalidtimeofastandingorderexceeds24hours.49精选StandingOrderAstandingorderSTATOrderThevalidtimelimitofaSTATorder

iswithin24hours,usuallyonlyonce.SometimesaSTAT(ST)ordersignifiesthatasingledoseofmedicationistobegivenimmediately.安定5mghs.50精选STATOrderThevalidtimelimitPRNOrderPRNorderisakindofstandingorder.ThephysicianmayorderatreatmentonaPRNbasisiftheclient'sconditionneeds.Oftenthephysiciansetsminimalintervalsbetweentwotimesofadministration.度冷丁50mgimq6hprn51精选PRNOrderPRNorderisakindoSOSOrderThevalidtimeoftheSOSorderiswithin12hours.Itwillbecarriedoutonlyonceasthestateofanillnessneeds.Itbecomesinvalidifitexceedsthetimelimit.52精选SOSOrderThevalidtimeoftheManagingPhysicianOrder

MethodofHandlingPrinciplesofManaging53精选ManagingPhysicianOrderMethoStandingOrdertransferstheordersontovarioustypesofforms.Thestandingorderstransferredontotheimplementationformswhicharecarriedoutinappointedtimeshouldbesignedspecificadministeredtime.54精选StandingOrdertransferstheoPRNordertransfersthemontovarioustypesofforms.Ifthephysiciansetsminimalintervalsbetweentwotimesofadministration,eachtimethenursecarriesoutthePRNorder,heorshehastodocumenttheexacttimeandsignfullname.55精选PRNordertransfersthemontovSTATOrder“st”meansexecutinganorderimmediately.Aftercarryingouttheorder,thenursehastosignhisorhernamein“executer”columnandnotesthetimeofexecuting.penicillinpositive(＋)negative(－)penicillinskintest56精选STATOrder“st”meansexecutingSOSorderSOSordershouldbecarriedoutonlyonceasthestateofanillnessneeds.Theperson,whocarriesouttheorder,signshisorhernamein“performer”columnandnotesthetimeofexecuting.Theorderbecomesinvalidifitexceedsthetimelimit.Thenursewritestheword“unexecuted”,documentsthetimeandsignshername.57精选SOSorderSOSordershouldbecStoptheOrderIfaphysiciandecidestostopanorderforsomereasons,thenursecancelstheorderinrelatedtreatmentsheetfirst.writedownthedateandtimein“stop”columninphysicianordersheet.58精选StoptheOrderIfaphysiciandRe-arrangingtheOrderdrawaredlinebelowthelastrowofphysicianorders,write“Rearranging”inthemiddlebelowtheredlinewitharedpen,andtranscribeoriginalvalidphysicianordersontospacesbelowtheredline.Twonursesverifytherearrangedordersandsigntheirnames.Aftertheoperation,childbirthortransferring,physicianordershavetoberearrangedtoo.Drawaredlinebelowthelastrowoforiginalorders,andwrite“post-operationorder”,“post-childbirthorder”,59精选Re-arrangingtheOrderdrawarUrgentBeforeRoutine.Whenmanagingseveralphysicianorders,itisnecessarytoseewhichorderismoreimportantorurgenttotheclient,andgivepriorityforcarryingitout.PrinciplesofManaging60精选UrgentBeforeRoutine.PrincipSTATOrderBeforeStandingOrder.

ItisroutinetocarryoutaSTATorderbeforeastandingone.PrinciplesofManaging61精选STATOrderBeforeStandinTheordercouldnotbechanged.Ifitistobecanceled,note“cancel”witharedpenandsign.PrinciplesofManaging62精选TheordercouldnotbechangedGenerallyspeaking,thephysicianshouldnotgiveoralorders.Intheeventsofanemergencyorduringoperationwhenthephysiciangivesordersorallytonurses,thenurseshavetorepeattheorderonceagainandmakesureitiscorrect.Aftertheemergencyhasbeenallayedandthephysicianshouldrecordandsignallordersthatweregiven.PrinciplesofManaging63精选Generallyspeaking,thephysicIfaSTATorSOSorderistobecarriedoutonthenextshift,theordershouldbewrittendowninthenursingnotes.PrinciplesofManaging64精选IfaSTATorSOSorderistobThephysicianordersmustbecheckedineveryshiftandtotallyonceeveryweek.PrinciplesofManaging65精选PrinciplesofManaging65精选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精选clinicalinformationsystem,CRecordingFluidIntakeandOutputContentsMethodsforRecording67精选RecordingFluidIntakeandOutContents出入液量记录单fluidintakefluidoutputoralfluidintakefoodintakeintravenousfluidinfusions

urine,stool,vomit,bleeding,sputum,gastricsuction,anddrainagefrompost-surgicaldrainagetubes.

68精选Contents出入液量记录单fluidintakefl69精选69精选Daytime'sfluidintakeandoutput

arerecordedwithablue-blackinkedorcarboninkedpen;nighttime'sfluidintakeandoutput

arerecordedwitha

redpen.intakeandoutput

aresummarizedattheendofeach12-hourand24-hourperiod.Sum

ofintakeandoutputof24-hourperiodisfilledincorrespondingcolumnofthetemperaturesheet.MethodsforRecording70精选Daytime'sfluidintakeandoutRecordingSpecialNursingContentsofrecordMethodsandRecommendationsforRecording71精选RecordingSpecialNursingConteContentsofrecordvitalsignslevelofconsciousnessfluidintakeandoutputstateofillnessnursinginterventionresponsetomedicationsignature72精选Contentsofrecordvitalsigns7MethodsandRecommendations特别护理记录单73精选MethodsandRecommendations特别护74精选74精选Change-of-shiftreportComponentsofReportRecommendations

75精选Change-of-shiftreportComponenComponentsofReportDischarge,Transfer-out,andDeathReportAdmission,Transfer-inReportSeverelyIllClients'ReportPostoperativeClients'ReportPre-operation,pre-diagnosticStudiesPreparationReport76精选ComponentsofReportDischarge,TopPart

OrderofWriting

Warddatetimetotalnumberofclients

numberofclientadmission

discharge

transferOperation

childbirth

clientsincriticalstatedeath.discharge,transfer-out,deathadmission,transfer-inoperativeclients,clientswhogivesbirth,criticallyillclients,andclientsofunusualcondition77精选TopPartOrderofWritingWard78精选78精选病人情况日夜报告

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