护理文书书写课件

Nursing Documentationpurpose of municatingcommunicating2.2.Providing theoretical basis for Providing theoretical basis for planning client treatment and careplanning client treatment and care3.3.Providing data for education and Providing data for education and researchresearch4.4.Providing basis for quality reviewProviding basis for quality review5.5.Providing basis for legal purposeProviding basis for legal purposepurpose of recordscommunicatprinciple of record1 1、recording procedures in timerecording procedures in time2 2、accuracyaccuracy3 3、completenesscompleteness4 4、objectivityobjectivity5 5、well-organized presentationwell-organized presentationprinciple of record1、recordi医疗与护理文件的管理管理要求管理要求1.1.各种护理文件按规定放置，记录和使用后必须放回各种护理文件按规定放置，记录和使用后必须放回2.2.必须保持医疗护理文件的清洁、整齐、完整、防止污染、必须保持医疗护理文件的清洁、整齐、完整、防止污染、破损、拆散、丢失破损、拆散、丢失3.3.患者和家属不得随意翻阅医疗护理文件的记录资料，不患者和家属不得随意翻阅医疗护理文件的记录资料，不得擅自将医疗护理文件带出病区得擅自将医疗护理文件带出病区4.4.医疗文件应妥善保存：出院或死亡的病案应整理后交病医疗文件应妥善保存：出院或死亡的病案应整理后交病案室，并按卫生行政部门规定的保存期限保管。体温单、案室，并按卫生行政部门规定的保存期限保管。体温单、医嘱单、特别护理记录单长期保存。病区交班报告本保医嘱单、特别护理记录单长期保存。病区交班报告本保存存1 1年，以备查阅。年，以备查阅。5.5.发生医疗事故纠纷时，应在发生医疗事故纠纷时，应在医患双方同时在场医患双方同时在场的情况下的情况下封存，并由封存，并由医疗机构负责医疗服务质量监控的部门医疗机构负责医疗服务质量监控的部门或专或专职人员保管。职人员保管。医疗与护理文件的管理管理要求 放置位置放置位置病病历历夹夹病病历历车车病案室病案室 放置位置病病病案室管理要求order of admission record1、temperature sheet2、physicians order sheet3、admission record4、The history and physical examination5、physicians record6、consultation record7、diagnostic studies reports8、nurses record9、standing order execute sheet10、first page of client record11、outpatient recordorder of discharge(transfer,death)record)1、first page of client record2、discharge or death record3、admission record4、The history and physical examination5、physicians record6、consultation record7、diagnostic studies reports 8、nurses record9、physicians order sheet 10、standing order execute sheet11、temperature sheet12、outpatient record is given back to the client or the clients family管理要求order of admission reco护理文书书写课件护理文书书写课件writing nursing documentswriting nursing documents1、temperature sheet2、managing physicians order3、recording fluid intake and output4、recording special nursing5、reporting clients conditions6、nursing historywriting nursing documents1、tem1、temperature sheetThe temperature sheet is used to record the temperature,pulse,respiration,blood pressure,body weight,fluid intake and output,urine,bowel movements,and admission time,discharge time,operation time and so on.The temperature sheet is on the first page of clients hospitalization record.1、temperature sheetThe tempera1.This part must be filled in with a blue-inked or carbon inked pen.2.Clients name,age,ward,bed number,admission date and time,and hospitalization number must be filled in legibly and completely.3.When writing“date”,year,month and day must be filled in the first day column of every page.As for the rest six days column only“day”is to be filled.Year,month,and day or month and day must be filled in if a new month or a new year starts within the six days.Filling in top partThis part must be filled in wi4、Days of hospitalization are written in Arabic number“1,2,3”from the day of admission to the day of discharge.5、The next day of operation(childbirth)is regard as the first day of operation(childbirth)that has been charted continuously on the day column of temperature sheet in Arabic number“1,2,3”until 14 days.If second operation has been done within 14 days,then stop writing the number of days of the first operation,filling in-0 on the day column of the second operation in Arabic number until the 14days.Filling in top part4、Days of hospitalization are 眉栏眉栏济宁医学院附属济宁医学院附属张三张三张三张三心内科心内科心内科心内科5 5床床床床2010-12-292010-12-296875366875362010-12-292010-12-29303031312011-01-012011-01-012 23 32 23 34 45 56 67 71 12 23(2)3(2)4 41 11/41/4体温记录单体温记录单 眉栏济宁医学院附属张三心内科5床2010-12Filling in between 40 -42 column of temperature sheetThis part is filled in with a blue-black inked or carbon inked pen.Time of admission,operation,childbirth,transfer,discharge or death is filled in the vertical line of corresponding time column between 40 -42 column of temperature sheet.When recording the time of admission and death,it is essential to specify the minuteFilling in between 40 -42 cFilling in between 40 -42 column of temperature sheetMethod and location:the nurse should write in longitudinal line:“admission-nine thirty,”operation-ten oclock.If the time of operation or other items is not equal to the time at temperature sheet,fill in the proximal time column.For example,if admission is at 11 oclock,then fill within“10”oclock column.If operation is on 1 oclock in the afternoon,then fill within“2”oclock column.Filling in between 40 -42 c4040404042424242横线之间横线之间横线之间横线之间入院入院入院入院-八时二十分八时二十分八时二十分八时二十分分娩于二十时十三分分娩于二十时十三分分娩于二十时十三分分娩于二十时十三分转出转出转出转出-九时二十分九时二十分九时二十分九时二十分出院出院出院出院-十五时三十分十五时三十分十五时三十分十五时三十分4042横线之间入院-八时二十分分娩于二十时十三分转出Drawing body temperature curve and sphygmogram1.Oral temperature is represented by blue“”,Axillary temperature is represented by blue“X”,Rectal temperature is represented by blue“”.Two adjacent readings are connected by blue line.2.If there is any reason that a clients body temperature has not been measured,3.A client with hyperpyrexia needs to have his or her body temperature taken again in half an hour after receiving physical therapy for lowering body temperature.4.For clients who need close observation of body temperature,5.If a clients body temperature is below 35,drawing body temperature curveDrawing body temperature curve体温的绘制体温的绘制T曲线绘制曲线绘制v不升体温的绘制T曲线绘制v不升Drawing sphygmogram1.Pulse rate is drawn in red “”,and heart rate is in red“”.Two corresponding readings of pulse rate or heart rate are connected by red line.2.If the reading of body temperature and pulse rate are at the same point xDrawing sphygmogramPulse rate 脉搏的绘制脉搏的绘制P、心率曲线绘制、心率曲线绘制脉搏短绌脉搏短绌脉搏的绘制P、心率曲线绘制脉搏短绌Respiration Readings of respiration are recorded in corresponding time columns.It is filled in by using a blue-black inked or carbon inked pen.18181818191920202222191918181818Respiration Readings of respir体温单34以下各栏目，用蓝黑、碳素墨水笔填写。体温单34以下各栏目，用蓝黑、碳素墨水笔填写。Filling in bottom part1.Blood pressure2.Body weight3.Bowel movement4.Intravenous infusion fluid and urine5.Page numberFilling in bottom partBlood pr底栏底栏2.Managing physicians order The physicians order is usually a written order prescribed by the physician in the process of treatment.Contents of physicians order：Date,time,routine care.Grade of nursing,diet.Body position,medication(name,dosage),routes of administration,physicians signature,and nurses signature.2.Managing physicians order T医嘱范例：呼吸内科护理常规一级护理低脂饮食吸氧 prn 5%葡萄糖 250ml氨茶碱 500mg速尿20mg iv stst 舒乐安定 5mg.po.sos明晨禁食行B超检查 2013-10-19 9:00am张平ivgtt.qd医嘱范例：呼吸内科护理常规2013-10-19 9:00amstanding order：a standing order is valid until it is cancelled by the physician or the prescribed number of days elapses.usually the valid time of a standing order exceeds 24 hours.Types of physicians order一级护理一级护理心内科护理常规心内科护理常规低盐饮食低盐饮食消心痛消心痛10mg po tid一级护理一级护理半流质饮食半流质饮食10%葡萄糖葡萄糖250ml+氨苄西林氨苄西林3.0g ivgtt qdstanding order：a standing ordstat order：a STAT order signifies that a single dose of medication is to be given immediately,usually only once.The valid time limit of a STAT order is within 24 hours.1.需立即执行，阿托品0.5mg H.st.2.需在限定时间内执行，会诊、手术、血、尿、粪常规检查，X线摄片及各项特殊检查等3.出院、转科、死亡也属于临时医嘱4.需一日内连续用药数次者，按临时医嘱处理。如奎尼丁0.2g po q2h5Types of physicians orderstat order：a STAT order signiTypes of physicians order备用医嘱备用医嘱：(1)(1)PRN orderPRN order：PRN order is a kind of PRN order is a kind of standing order.The physician may order a standing order.The physician may order a drug on a PRN basis if the clients drug on a PRN basis if the clients condition needs.Often the physician sets condition needs.Often the physician sets minimal intervals between two times of minimal intervals between two times of administration.This means that a drug administration.This means that a drug cannot be given more frequently than what is cannot be given more frequently than what is prescribed.prescribed.An example of PRN order is An example of PRN order is Dolantin(Dolantin(杜冷丁杜冷丁)50mg IM q6h prn.50mg IM q6h prn.Types of physicians order备用医嘱Types of physicians order备用医嘱备用医嘱：(2)(2)sos order:the valid time of the sos order:the valid time of the SOS order is within 12 hours.It will SOS order is within 12 hours.It will be carried out only once as the state be carried out only once as the state of an illness needs.It becomes of an illness needs.It becomes invalid if it exceeds the time limit,invalid if it exceeds the time limit,for example,Dolantin 50mg IM SOS.for example,Dolantin 50mg IM SOS.Types of physicians order备用医嘱护士签名护士签名李丽李丽刘凤刘凤维生素维生素B110mg po tid、维生素维生素E0.1g po tid、测测BP、pq6h刘凤刘凤9:0005-04、青霉素青霉素80万万u imbid、半流质饮食半流质饮食、二级护理二级护理内科常规护理内科常规护理9:002010-05-02医师医师签名签名时间时间日期日期时间时间日期日期停停 止止护士护士签名签名医师医师签名签名 医嘱内容医嘱内容 开开 始始长期医嘱单长期医嘱单姓名 陈敏 病区 内科 床号 5床 住院号20100578刘凤刘凤护士签名李丽刘凤维生素B110mg po tid、维生素E临时医嘱单临时医嘱单姓名 陈敏 病区 内科 床号 5床 住院号20100578时时 间间日日 期期刘凤刘凤X线胸片线胸片、心电图心电图、小便常规小便常规、大便常规大便常规、血常规血常规、明晨抽血测明晨抽血测k、安定安定10mg im sos、阿托品阿托品0.5mg im st青霉素皮试（青霉素皮试（）9:002010-05-02执行执行者签者签名名执行时间执行时间医师医师签名签名医医 嘱嘱 内内 容容 开开 始始刘凤刘凤临时医嘱单姓名 陈敏 病区 内科 长期医嘱处理长期医嘱处理护护士士将将长长期期医医嘱嘱单单上上的的医医嘱嘱分分别别转转抄抄至至各各种种执执行行卡卡上上，转转抄抄时时须须注注明明执执行行的的具具体体时时间间并并签签全全名名。护护士士执执行行长长期期医医嘱嘱后后应应在在长长期期医医嘱嘱执执行行单单上上注注明执行的时间，并签全名。明执行的时间，并签全名。Managing physicians order长期医嘱处理Managing physicians ord护士护士签名签名刘凤刘凤维生素维生素B110mg po tid、维生素维生素E0.1g po tid、测测BP、pq6h李丽李丽、青霉素青霉素80万万im bid、半流质饮食半流质饮食、二级护理二级护理刘凤刘凤内科常规护理内科常规护理9:002010-05-02医师医师签名签名时间时间日期日期时间时间日期日期停停 止止护士护士签名签名医师医师签名签名 医嘱内容医嘱内容 开开 始始长期医嘱单长期医嘱单姓名 陈敏 病区 内科 床号 5床 住院号20100578l护士将长期医嘱栏内的医嘱分别转抄至各种执行单上(如服药单、注射单、输液单、饮食单等)肌注卡 姓名 陈敏 科室 内 床号 30 青霉素80万 im 8-4pm转抄后在医嘱单转抄后在医嘱单上签全名上签全名护士签名刘凤维生素B110mg po tid、维生素E0.临时医嘱处理临时医嘱处理需立即执行的医嘱，护士执行后，必须注明执需立即执行的医嘱，护士执行后，必须注明执行时间并签上全名。行时间并签上全名。有限定执行时间的临时医嘱，护士应及时转抄有限定执行时间的临时医嘱，护士应及时转抄至临时治疗本或交班记录本上。会诊、手术、至临时治疗本或交班记录本上。会诊、手术、检查等各种申请单应及时送到相应科室。检查等各种申请单应及时送到相应科室。Managing physicians order临时医嘱处理Managing physicians ord临时医嘱单临时医嘱单姓名 陈敏 病区 内科 床号 5床 住院号20100578时时 间间日日 期期刘凤刘凤X线胸片线胸片、心电图心电图、小便常规小便常规、大便常规大便常规、血常规血常规、明晨抽血测明晨抽血测k、安定安定10mg im sos王兰王兰、阿托品阿托品0.5mg im st9:30刘凤刘凤青霉素皮试（青霉素皮试（）9:002010-05-02执行执行者签者签名名执行时间执行时间医师医师签名签名医医 嘱嘱 内内 容容 开开 始始写在临时医嘱栏内，护士在执行后，必须写上执行时间并签全名。临时医嘱单姓名 陈敏 病区 内科 备用医嘱处理备用医嘱处理长期备用医嘱：由医生开写在长期医嘱单上，长期备用医嘱：由医生开写在长期医嘱单上，必须注明执行时间。如哌替啶必须注明执行时间。如哌替啶50mg im q6h prn50mg im q6h prn。护士每次执行后，在护士每次执行后，在临时医嘱单临时医嘱单内内记录执行时记录执行时间并签全名，以供下一班参考。间并签全名，以供下一班参考。临时备用医嘱：由医生开写在临时医嘱单上，临时备用医嘱：由医生开写在临时医嘱单上，12h12h内有效。地西泮内有效。地西泮5mg po sos,5mg po sos,若过时未执行，若过时未执行，则由护士用则由护士用红笔红笔在该项医嘱栏内写在该项医嘱栏内写“未用未用”二二字。字。Managing physicians order备用医嘱处理Managing physicians ord停止医嘱处理停止医嘱处理把相应把相应执行单上执行单上的有关项目的有关项目注销注销，同时注明停，同时注明停止日期和时间止日期和时间在医嘱单在医嘱单原医嘱后，填写停止日期、时间原医嘱后，填写停止日期、时间，最，最后在执行者栏内签全名后在执行者栏内签全名Managing physicians order停止医嘱处理Managing physicians ordManaging physicians order重整医嘱处理：重整医嘱处理：凡长期医嘱单超过凡长期医嘱单超过3 3张，或医张，或医嘱调整项目较多时需重整医嘱。嘱调整项目较多时需重整医嘱。由医生在原医嘱最后一行下面划一红横线，在由医生在原医嘱最后一行下面划一红横线，在红线下用红线下用红笔红笔写写“重整医嘱重整医嘱”（“术后医嘱术后医嘱”、“分娩医嘱分娩医嘱”、“转入医嘱转入医嘱”等），再将红线等），再将红线以上有效的长期医嘱，按原日期、时间的排列以上有效的长期医嘱，按原日期、时间的排列顺序抄于红线下。抄录完毕核对无误后签上全顺序抄于红线下。抄录完毕核对无误后签上全名。名。医生重整医嘱后，由当班护士核对无误后在整医生重整医嘱后，由当班护士核对无误后在整理之后的有效医嘱执行者栏内签上全名。理之后的有效医嘱执行者栏内签上全名。Managing physicians order重整医嘱Executing before transcribingExecuting before transcribingUrgent before routineUrgent before routineSTAT Order before STANDING Order STAT Order before STANDING Order One order only includes one subject,noting time One order only includes one subject,noting time in minute manner.The nurse has responsibility for in minute manner.The nurse has responsibility for checking its correctness.checking its correctness.The order could not be changed.If it is to be The order could not be changed.If it is to be canceled,note“cancel”with a red pen and sign.canceled,note“cancel”with a red pen and sign.Generally speaking,the physician should not give Generally speaking,the physician should not give oral orders.oral orders.If a STAT or SOS order is to be carried out on If a STAT or SOS order is to be carried out on the next shift,the order should be written down the next shift,the order should be written down in the nursing notes.in the nursing notes.Principles of managingPrinciples of managingAfter transcription or rearrangement,the orders After transcription or rearrangement,the orders have to be checked by two nurses with their have to be checked by two nurses with their signatures.The physicians orders must be signatures.The physicians orders must be checked in every shift and totally once every checked in every shift and totally once every week.week.Person who carries out the physicians order Person who carries out the physicians order has to sign his or her full name in the treatment has to sign his or her full name in the treatment sheet and physicians order sheet.sheet and physicians order sheet.Principles of managingPrinciples of managing3.Recording fluid intake and outputA healthy adult can usually maintain normal intake and output fluid balance.Imbalances may occur if a client has cardiovascular disease,renal disease,severe burns,hemorrhage,or extensive surgery.3.Recording fluid intake and oRecording fluid intake and outputfluid intakeFluid intake includes daily oral fluid intake,food intake,and intravenous fluid infusions etc.fluid outputThe major fluid output is urinary output.Other output fluids include amount of stool,vomit,bleeding,sputum,gastric suction,and drainage from post-surgical drainage tubes.Recording fluid intake and outRecording fluid intake and outputMethods for recordingMethods for recordingThe heading must be documented with blue-black inked or carbon inked pen.Amounts of fluid intake and output are usually recorded in ml.Intake and output at the same time are recorded on the same transverse line,and those at different times are recorded on respective lines.Recording fluid intake and outRecording fluid intake and outputMethods for recordingMethods for recordingDaytimes 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.Various types of intake and output are summarized 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.Recording fluid intake and out出入液量记录单日期时间 入量 出量签名项目量（ml)项目 量（ml)、07:00、19：0012h小结、07：0024h总结姓名 床号 诊断 科别 病房 住院号 出入液量记录单 入量 出量项目量护理文书书写课件4.Recording special nursingSpecial nursing record made by nurses provides information about conditions of a severely ill client or postoperative client,treatment and nursing care provided,and progress toward achieving desired outcomes according to the physicians orders and clients conditions.4.Recording special nursingSpspecial nursing recordContents of recordContents of recordInformation commonly found in the special Information commonly found in the special nursing record sheet includes a clients basic nursing record sheet includes a clients basic demographic data(e.g.,name,age,ward number,demographic data(e.g.,name,age,ward number,bed number,and admission hospital bed number,and admission hospital number),vital signs,level of consciousness,number),vital signs,level of consciousness,fluid intake and output,state of illness,fluid intake and output,state of illness,nursing intervention,response to medication,nursing intervention,response to medication,and signature.Documentation of nursing care and signature.Documentation of nursing care for critically ill client should be specified for critically ill client should be specified according to medical specialty.according to medical specialty.special nursing recordConte护理文书书写课件Methods and recommendations for recordingAll the parts must be recorded with a blue-black inked penRecord is made objectively according to current physicians and changes of clients conditions.Recording should be timely and exact in reflecting the changes of the clients conditions.special nursing recordMethods and recommendations foMethods and recommendations for recordingIt is unnecessary to chart a routine daily care,such as changing bed and morning care.Routinely measured vital signs are drawn in the temperature sheet.It is improper to copy the physicians note.Record should be complete and legible.The clients total intake and output,conditions,treatment and care are summarized at the end of each 12-hour and 24-hour period.special nursing recordMethods and recommendations fo5.Reporting clients conditionsClients condition report is a written report in which the nurses give information about dynamic changes of clients conditions during the period of their shift.Components of reportDischarge,transfer-out,and death reportAdmission,transfer-in reportSeverely ill clients reportPostoperative clients reportPre-operation,pre-diagnostic studies preparation report.5.Reporting clients condition书写顺序用蓝钢笔填写眉栏所列的各项 根据下列顺序，按床号先后书写1.出科（出院、转出、死亡）2.入科（入院、转入）3.病重（病危）、当日手术患者、病情变化患者、次日手术及特殊治疗检查患者、外出请假及其他有特殊情况的患者。Reporting clients conditions书写顺序Reporting clients conditi书写要求应在经常巡视和了解病情的基础上书写；白班用蓝黑、碳素墨水笔填写，夜间用红色笔填写。书写内容应全面、真实、简明扼要、重点突出；眉栏项目包括当日住院患者总数、出院、入院、手术、分娩、病危、病重、抢救、死亡等患者数。填写时，先写姓名、床号、诊断；后报告生命体征，并注明时间；再简要记录病情、治疗和护理；对新入院、转入、手术、分娩患者，在诊断的右下方用红笔注明“新新”“”“转入转入”“”“手术手术”“”“分娩分娩”，危重患者做红色标记“*”或“危危”；写完后注明页数并签名；护士长应每班检查，符合质量后签全名。Reporting clients conditions书写要求Reporting clients conditi书写要求出科出科患者：记录床号、姓名、诊断、转归。入科入科患者及转入转入患者：记录床号、姓名、诊断及重点交接内容。其重点内容为主要病情、护理要点（管道情况、皮肤完整性、异常心理及其护理安全隐患等）、后续治疗及观察。病重（病危）患者：记录床号、姓名、诊断。病情变化等记录在病重（病危）患者护理记录单上。手术患者：记录手术名称、回病房的时间、当班实施的护理措施、术后观察要点及延续的治疗等。病情变化的患者：记录本班主要病情变化、护理措施及下一班次护理观察要点和后续治疗。书写要求书写要求 次日手术的患者：记录术前准备，交待下一班次观察要点及相关术前准备情况等。特殊治疗的患者：记录所做治疗的名称、护理观察要点及注意事项。特殊检查的患者：记录检查项目、时间、检查前准备及观察要点等。外出请假的患者：记录去向、请假时间、医生意见、告知内容等。其他：患者有其他特殊及异常情况时要注意严格交接班，如情绪或行为异常、跌倒、摔伤等不良事件等。书写要求 次日手术的患者：记录术前准备，交待下一班次20102010This part mainly introduces different formats in nursing history.The techniques of how to apply nursing process in data collection,planning,intervention and evaluation.Forms used for nursing historyAdmission assessment sheetImpatient assessment sheetNursing plan sheetNursing record sheetHealth education plan sheet6.Nursing historyThis part mainly introduces di60Nursing historyAdmission assessment sheet用于对新入院患者进行的初步护理评估，并通过评估找出患者的健康问题，确立护理诊断。主要内容包括患者的一般资料、现在健康状况、既往健康状况、心理状况、社会状况等。60Nursing historyAdmission ass61Nursing historyImpatient assessment sheet及时、全面掌握患者病情的动态变化，护士应对其分管的患者视病情每班、每天或数天进行评估。61Nursing historyImpatient ass62Nursing historyNursing plan sheet是护理人员对患者实施整体护理的具体方案。包括护理诊断、护理目标、护理措施和效果评价等。62Nursing historyNursing plan 63Nursing historyNursing record sheet是护士运用护理程序的方法为患者解决问题的记录。包括患者的护理诊断问题、护士所采取的护理措施和执行措施后的效果等。常采记录格式有两种：（1）P（problem）、I（intervention）、O（outcome）格式（简称PIO格式）（2）S（subjective data）、O（objective data）、A（assessment）、P（plan）、E（evaluation）格式（简称SOAPE格式）63Nursing historyNursing recor64Nursing historyHealth education plan sheet是为恢复和促进患者健康，而制定和实施帮助患者掌握健康知识的学习计划与技能训练计划包括：(1)住院期间的健康教育计划 (2)出院指导64Nursing historyHealth educat护理文书书写课件护理文书书写课件