护理 英文 完整 护理文件书写课件.ppt

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1、精选,1,Chapter 16 Nursing Documentation,精选,2,medical and nursing documents,clients record,A clients medical recordTemperature sheet Physicians order sheetspecial nursing record chart,etc.,Change-of-shift report(病室交班报告),精选,3,Section 1 Record and Administration of medical and Nursing Documents,Purpose o

2、f Records,Principle of Records,Administration of Medical and Nursing Documents,精选,4,Purpose of Records,Providing Data for Education and Research,精选,5,Principles of Records,精选,6,follow the hospitals requirement to make documentation at regular intervals.,No recording should be done before providing n

3、ursing cares,and delaying or omitting the recording is not acceptable either.,精选,7,Recording must be accurate and correct.,Accurate recordings consist of facts or observations rather than opinions or interpretation.,精选,8,The clients name,age,and bed number,should be written on each page of the recor

4、d.,Leaving no blank lines on the clients chart.,the caregiver must sign his or her full name after recording.,a clients condition is critical.a client insists on refusing a treatment or leaving the hospital against medical advice.a client has inclination of committing suicide.,these situations must

5、be filled in the clients chart.,精选,9,Documentation must be concise,in a logical order,and lay stress on key points.,精选,10,All entries must be legible and easy to read.When a recording error is made,draw a line through it and write the correctors name above it.Do not erase,blot out,or use correction

6、fluid.,精选,11,Administration of Medical and Nursing Documents,Administration Requirements,Arrangement Order of Medical Record,精选,12,Administration Requirements,精选,13,All medical and nursing documents should be placed according to organization guidelines.They should be replaced after being read or rec

7、orded.,精选,14,Medical and nursing documents must be kept neatly,orderly,completely and prevent them from being contaminated,mangled,disconnected and lost.,精选,15,The client or the clients family should not read the medical and nursing documents freely.No carrying the documents out of the ward without

8、being permitted.If the documents need to be carried out of the ward for the purpose of medical activity or copy,it should be carried and kept well by hospital appointed staff.,精选,16,All the documents should be kept properly.When the client is discharged from the hospital,temperature sheet,physicians

9、 order sheet and special nursing record chart will be kept permanently in Medical Recording Room of the hospital as parts of the clients case-notes.The change-of-shift report will be kept at least one year at the ward level.,精选,17,Arrangement Order of Medical Record,Order of Admission Record,Order o

10、f Discharge(transfer,death)Record,精选,18,Order of Admission Record,Temperature sheetPhysicians order sheetAdmission sheet and recordmedical history and physical examination Physicians recordConsultation recordDiagnostic studies reports Special nursing recordFirst page of client recordAdmission sheetO

11、utpatient record,精选,19,Order of Discharge(transfer,death)Record,First page of client recordAdmission sheet(if client died,adding death report sheet)Discharge or death recordAdmission recordmedical history and physical examination Physicians record Consultation recordDiagnostic studies reports specia

12、l nursing recordPhysicians order sheetTemperature sheet Outpatient record is given back to the client or the clients family.,精选,20,Section 2 Writing Nursing Documents,Temperature Sheet,Managing Physicians Order,Recording Special nursing,Reporting Clients Conditions,精选,21,中国医疗信息化的发展,医院信息系 统(hospital

13、information system,HIS)面向临床工作的医院临 床信息系统(clinical information system,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。,精选,22,Temperature Sheet,It is on the first page of clients hospitalization record.it provides the staff with a quick summary of all the clients condition and vital signs

14、on the sheet.,精选,23,精选,24,Filling in Top Part,This part must be filled in with a blue-black inked or carbon inked pen.Clients name,sex,age,ward,admission date and hospitalization number must be filled in completely.,year,month and day must be filled in the first day column of every page.,the rest si

15、x days column only“Day”,精选,25,Filling in Between 4042 Column of Temperature Sheet,Time of admission,operation,childbirth,transfer,discharge or death is filled in the vertical line of corresponding time column with a red inked pen between 40 42 column.it is essential to specify the minute.If the time

16、 is not equal to the time at temperature sheet,fill in the proximal time column.,精选,26,Drawing Body Temperature CurveDrawing Sphygmogram,精选,27,Drawing Body Temperature Curve,Oral temperature:“”，Axillary temperature“，Rectal temperature“”.Two adjacent readings are connected by blue line.,精选,28,A clien

17、t with hyperpyrexia needs to have the body temperature taken again in half an hour after receiving physical therapy.The reading of measured temperature is drawn in the same longitudinal column of previous reading by red“”,and connected with the reading before physical therapy by red dotted line.The

18、reading of next measurement is still connected with the reading before physical therapy.,精选,29,a clients body temperature is below 35,不升,不升,Reading of measured temperature is represented by blue“”,and connected with the adjacent readings.,精选,30,Drawing Sphygmogram,Pulse rate is drawn in red“”,Two co

19、rresponding readings of pulse rate are connected by red line.,精选,31,pulse deficit,heart rate is in red“”.Two corresponding readings of heart rate are connected by red line.filled in the area between the line of pulse rate and the line of heart rate in red line.,精选,32,If the reading of body temperatu

20、re and pulse rate are at the same point,draw the temperature first in blue“”,then draw a red circle()outside the blue“”to represent the pulse rate.,精选,33,Respiration,Readings of respiration are recorded in corresponding time columns in Arabic number with blue pen and the numbers are written alternat

21、ively upward and downward.,精选,34,Filling in Bottom Part,All this part is filled in by using a blue-black inked or carbon inked pen.Arabic number represents the readings.Calculation unit is omitted.Contents：,精选,35,Bowel Movement,Document the bowel movement on the previous day.If there is no bowel mov

22、ement,document 0;fecal incontinence is documented as;“E”represents enema.(0/E;11/E),Document the number of times once a day,1/E represents one time of defecation after enema.,精选,36,Fluid intake and output,Document the total amount of Fluid intake and output of the previous day(during a 24-hour perio

23、d)according to the physicians order.the amount of intake and output fluids are recorded in ml.,Fluid output,Fluid Intake,精选,37,Blood Pressure,If more measuring is needed,the readings of measurement can be recorded in the nursing notes.,Readings of blood pressure are recorded in corresponding time co

24、lumns.,110/75,105/70,精选,38,Body Weight,Fill it in the unit of kg.When a client is admitted,the nurse measures his or her body weight and documents it in the corresponding time column.During hospitalization,measure and document body weight once a week.,精选,39,days of operation(childbirth),The next day

25、 of operation(childbirth)is regarded as the first day of operation(childbirth)that has been charted continuously on the day column in Arabic number“1,2,3.”until 10 days.,If a second operation has been done within 10 days,精选,40,Days of hospitalization,write in Arabic number“1,2,3.”from the day of adm

26、ission to the day of discharge.,精选,41,Page Number,Fill the page numbers in sequence.,精选,42,Managing Physicians Order,physician order recording book(医嘱本),physician order sheet(医嘱单),various types of forms that are necessary for implementation(各种执行单),精选,43,physician order recording book,床号 姓名 时间 医嘱 医生

27、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（）st 8am 黄华 10%GS500ml 青霉素640万u ivdrip qd 丁 胺卡那 0.2 im bid Vc 100mg tid 氧气吸入 p r n 李玲 2007-12-121-3 张利 4pm 停Vc 100mg tid 李玲 下午2点胸腔穿刺 2pm 吕新 安定 5mg hs 度冷丁 50mg im q6h 李玲,医 嘱 本山东大学齐鲁医院,精选,44,physician order sheet,STAT order Sheet,Standing

28、 order Sheet,精选,45,精选,46,various types of forms that are necessary for implementation,nursing grade sheetdiet sheetoral medication sheetinjection sheettreatment sheet,etc.,口服药1-3 张利8 12 4Vc 100mg土霉素 0.5 8pm 土霉素 0.5,精选,47,Contents of Physician Order,Date,Time,Bed No,Name,routine care grade of nursing

29、 diet body position,medication(name,dosage,routes of administration);pre-operation preparation;diagnostic Study and therapy,preparation for diagnostic test or surgery,physicians signature nurses signature,精选,48,Types of Physician Order,Standing Order STAT Order PRN Order SOS Order,精选,49,Standing Ord

30、er,A standing order is valid until it is cancelled by the physician.Usually the valid time of a standing order exceeds 24 hours.,精选,50,STAT Order,The valid time limit of a STAT order is within 24 hours,usually only once.Sometimes a STAT(ST)order signifies that a single dose of medication is to be gi

31、ven immediately.,安定 5mg hs.,精选,51,PRN Order,PRN order is a kind of standing order.The physician may order a treatment on a PRN basis if the clients condition needs.Often the physician sets minimal intervals between two times of administration.,度冷丁 50mg im q6h prn,精选,52,SOS Order,The valid time of th

32、e SOS order is within 12 hours.It will be carried out only once as the state of an illness needs.It becomes invalid if it exceeds the time limit.,精选,53,Managing Physician Order,Method of Handling,Principles of Managing,精选,54,Standing Order,transfers the orders onto various types of forms.The standin

33、g orders transferred onto the implementation forms which are carried out in appointed time should be signed specific administered time.,精选,55,PRN order,transfers them onto various types of forms.If the physician sets minimal intervals between two times of administration,each time the nurse carries o

34、ut the PRN order,he or she has to document the exact time and sign full name.,精选,56,STAT Order,“st”means executing an order immediately.After carrying out the order,the nurse has to sign his or her name in“executer”column and notes the time of executing.,penicillin positive()negative(),penicillin sk

35、in test,精选,57,SOS order,SOS order should be carried out only once as the state of an illness needs.The person,who carries out the order,signs his or her name in“performer”column and notes the time of executing.The order becomes invalid if it exceeds the time limit.The nurse writes the word“unexecute

36、d”,documents the time and signs her name.,精选,58,Stop the Order,If a physician decides to stop an order for some reasons,the nurse cancels the order in related treatment sheet first.write down the date and time in“stop”column in physician order sheet.,精选,59,Re-arranging the Order,draw a red line belo

37、w the last row of physician orders,write“Rearranging”in the middle below the red line with a red pen,and transcribe original valid physician orders onto spaces below the red line.Two nurses verify the rearranged orders and sign their names.After the operation,childbirth or transferring,physician ord

38、ers have to be rearranged too.Draw a red line below the last row of original orders,and write“post-operation order”,“post-childbirth order”,精选,60,Urgent Before Routine.When managing several physician orders,it is necessary to see which order is more important or urgent to the client,and give priorit

39、y for carrying it out.,Principles of Managing,精选,61,STAT Order Before Standing Order.It is routine to carry out a STAT order before a standing one.,Principles of Managing,精选,62,The order could not be changed.If it is to be canceled,note“cancel”with a red pen and sign.,Principles of Managing,精选,63,Ge

40、nerally speaking,the physician should not give oral orders.In the events of an emergency or during operation when the physician gives orders orally to nurses,the nurses have to repeat the order once again and make sure it is correct.After the emergency has been allayed and the physician should recor

41、d and sign all orders that were given.,Principles of Managing,精选,64,If a STAT or SOS order is to be carried out on the next shift,the order should be written down in the nursing notes.,Principles of Managing,精选,65,The physician orders must be checked in every shift and totally once every week.,Princ

42、iples of Managing,精选,66,clinical information system,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,精选,67,Recording Fluid Intake and Output,Contents,Methods for Recording,精选,68,Contents,出入液量记录单,fluid intake,fluid output,oral fluid intakefood intakeintravenous flu

43、id infusions,urine,stool,vomit,bleeding,sputum,gastric suction,and drainage from post-surgical drainage tubes.,精选,69,精选,70,Daytimes fluid intake and output are recorded with a blue-black inked or carbon inked pen;nighttimes fluid intake and output are recorded with a red pen.intake and output are su

44、mmarized at the end of each 12-hour and 24-hour period.Sum of intake and output of 24-hour period is filled in corresponding column of the temperature sheet.,Methods for Recording,精选,71,Recording Special Nursing,Contents of record,Methods and Recommendations for Recording,精选,72,Contents of record,vi

45、tal signslevel of consciousnessfluid intake and outputstate of illnessnursing interventionresponse to medication signature,精选,73,Methods and Recommendations,特别护理记录单,精选,74,精选,75,Change-of-shift report,Components of Report,Recommendations,精选,76,Components of Report,Discharge,Transfer-out,and Death Rep

46、ort Admission,Transfer-in Report Severely Ill Clients Report Postoperative Clients Report Pre-operation,pre-diagnostic Studies Preparation Report,精选,77,Top Part,Order of Writing,Ward date time total number of clients number of clientadmission discharge transfer Operation childbirth clients in critic

47、al state death.,discharge,transfer-out,death admission,transfer-in operative clients,clients who gives birth,critically ill clients,and clients of unusual condition,精选,78,精选,79,病人情况日夜报告日期年月日 护士长签字：,姓名 入院 病重床号 出院 手术 同左 同左诊断 转出 死亡3床 杜鹃 甲状腺瘤住院10天治愈于9am出院5床 许威 胃癌住院14天于4pm转普外科 19 床 T P R at 4pm T P R at

48、T P R at 庞月 患者 患者 患者上消化道穿孔并腹膜炎 新 31床 T P R at 吴军 肺癌 手术 护理要点：1、护士签名 护士签名 护士签名,精选,80,Recommendations,Record is on the basis of sound observation.The report should be concise,accurate and objective,and highlight important points.The report should be neat and legible.Do not erase.Daytimes conditions are

49、 recorded with a blue pen,and nighttimes conditions are recorded with a red pen.,精选,81,Entries are filled in the following orders:write down the bed numbername and diagnosis vital signs and the time of measuringthe clients conditions,treatment and nursing care provided,精选,82,For clients newly admitt

50、ed,transferred-in,having operation or childbirth,write down the word“New”,“Transfer”,“Operation”,and“Childbirth”in red under the words of diagnosis.For severely ill clients,it is highlighted by the symbol“”,or the word“critically ill”in red.,精选,83,After finishing the recording,write down the number