Nursing document records should be objective, true, accurate, timely, complete and signed. The day shift shall be written in blue ink, and the night shift shall be written in red ink (see the requirements of each sheet for details); Medical terms should be used when writing nursing documents. Common foreign abbreviations and symptoms, signs and disease names without official Chinese translations can be written in foreign languages; The sorting and page number marking of hospitalization and archived medical records meet the requirements.
1. Nursing document records should be objective, true, accurate, timely, complete and signed. The day shift shall be written in blue ink, and the night shift shall be written in red ink (see the requirements of each sheet for details).
2. Medical terms should be used when writing nursing documents. Common abbreviations in foreign languages and symptoms, signs and disease names without official Chinese translations can be written in foreign languages.
3. Nursing documents should be written neatly, with clear handwriting, accurate expression, smooth sentences and correct punctuation. When there is a wrong word in the writing process of the nurse on duty, she should use the same color pen to draw double lines on the wrong word, and use the same color pen to correct the wrong word above the line. It is not allowed to cover or remove the original handwriting by scraping, sticking, painting and other methods. Each page shall not be modified more than 2 times. Any digital error shall not be modified by the above methods.
4. Nursing records shall be written in accordance with the provisions and signed by registered nurses; The contents written by interns and probationary nurses shall be reviewed, modified and signed by the legally licensed nurses of the medical institution; After passing the examination by the Nursing Department and departments and reporting to the Nursing Department for filing, the refresher nurses can write nursing medical records independently. Those who fail the examination shall be reviewed, modified and signed by the teaching nurses who legally practice in their medical institutions.
5. The superior nursing staff has the responsibility to review and modify the nursing records written by the subordinate nursing staff. Red pen shall be used to draw double lines during modification, and red pen shall be used to correct and sign the full name and time above the crossed wrong words or sentences. The modification time limit shall be within 72 hours. Keep the original record clear and legible.
6. If the nursing record is not written in time due to rescue of critical patients, it shall be recorded and noted within 6 hours after the rescue.
7. The time of document recording shall be recorded in 24-hour Beijing time. The unit of measurement used shall be the legal unit of measurement of the People's Republic of China.
8. In order to maintain the consistency of medical and nursing records, nurses should communicate with doctors more when recording to avoid unnecessary misunderstandings and disputes.
9. Name and sequence of archived nursing documents: nursing handover sheet for surgical patients, long-term (temporary) medical advice record sheet, temperature sheet, admission nursing evaluation sheet, informed consent of nursing measures, critical care plan sheet, general nursing record sheet, critical care record sheet (general and critical nursing record sheet, sorted by date sequence) Other special nursing record sheets (such as brain surgery observation record sheets) and inpatient health education evaluation sheets, which are kept for a long time with the medical records. The doctor's order book and shift handover report book shall be kept by the department for three years.
10. The sorting and page numbering of inpatient and archived medical records meet the requirements.
11. The pages of nursing documents are clean, tidy and printed clearly. For the electronic printed nursing record sheet, the nurse must sign the full name manually.