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Chapter 16Nursing Documentation
medical and nursing documents A client's medical record Temperature sheet Physician’s order sheet special nursing record chart , etc. client's record Change-of-shift report
(病室交班报告)
Section 1 Record and Administration of medical and Nursing Documents Purpose of Records Principle of Records Administration of Medical and Nursing Documents
Providing Information Providing Basis for Legal Purpose Providing Basis for Quality Review Purpose of Records Providing Data for Education and Research
2 3 5 4 1 Timely Objective and Accurate Concise
Legible Complete Principles of Records
1 Timely • follow the hospital’s requirement to make documentation at regular intervals. • No recording should be done before providing nursing cares, and delaying or omitting the recording is not acceptable either.
2 Objective and Accurate Recording must be accurate and correct. Accurate recordings consist of facts or observations rather than opinions or interpretation.
3 Complete • The client's name, age, and bed number, should be written on each page of the record. •
Leaving no blank lines on the client's chart. • the caregiver must sign his or her full name after recording. • a client's 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 be filled in the client's chart.
4 Concise
Documentation must be concise, in a logical order, and lay stress on key points.
5 Legible • All entries must be legible and easy to read. • When a recording error is made, draw a line through it and write the corrector's name above it. • Do not erase, blot out, or use correction fluid.
Administration of Medical and Nursing Documents Administration Requirements Arrangement Order of Medical Record
Administration
Requirements
All medical and nursing documents should be placed according to organization guidelines. • They should be replaced after being read or recorded.
Medical and nursing documents must be kept neatly,
orderly, completely and prevent them from being contaminated, mangled, disconnected and lost.
The client or the client's family should not read the medical and nursing documents freely. • No carrying the documents out of the ward without 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.
All the documents should be kept properly. • When the client is discharged from the hospital, temperature sheet, physician’s order sheet and special nursing record chart will be kept permanently in Medical Recording Room of the hospital as parts of the client's case-notes. • The
change-of-shift report will be kept at least one year at the ward level.
Arrangement Order of Medical Record Order of Admission Record Order of Discharge (transfer, death) Record
Order of Admission Record • Temperature sheet • Physician’s order sheet • Admission sheet and record • medical history and physical examination • Physician's record • Consultation record • Diagnostic studies reports • Special nursing record • First page of client record • Admission sheet • Outpatient record
Order of Discharge (transfer, death) Record • First page of client record • Admission sheet (if client died, adding death report sheet) • Discharge or death record • Admission record • medical history and physical examination • Physician's record • Consultation record • Diagnostic studies reports • special nursing record •
Physician’s order sheet • Temperature sheet Outpatient record is given back to the client or the client's family.
Section 2 Writing Nursing Documents Temperature Sheet Managing Physician’s Order Recording Special nursing Reporting Client’s Conditions
中国医疗信息化的发展 • 医院信息系 统(hospital 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。
Temperature Sheet • It is on the first page of client's
hospitalization record. • it provides the staff with a quick summary of all the client's condition and vital signs on the sheet.
Filling in Top Part • This part must be filled in with a blue-black inked or carbon inked pen . • Client's 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 six days column only “Day”
Filling in Between 40℃~42℃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 is not equal to the time at temperature sheet, fill in the proximal time column.
Drawing Body Temperature Curve • Drawing Sphygmogram
Drawing Body Temperature Curve • Oral temperature :“●”， • Axillary temperature“×， • Rectal temperature“○”. Two adjacent readings are connected by blue line.
A client with hyperpyrexia needs to have the body
temperature taken again in half an hourafter 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 reading of next measurement is still connected with the reading before physical therapy.
a client's body temperature is below 35℃ 不升 不 升 Reading of measured temperature is represented by blue “×”, and connected with theadjacent readings.
Drawing Sphygmogram • Pulse rate is drawn in red “●”,Two corresponding readings of pulse rate are connected by red line.
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.
If the reading of body
temperature 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.
Respiration Readings of respiration are recorded in corresponding time columns in Arabic number with blue pen and the numbers are written alternatively upward and
downward.
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：
Bowel Movement Document the bowel movement on the previous day. If there is no bowel movement, document "0"; fecal incontinence is documented as "※"; “ E” represents enema. (0/E ; 11/E) 1 /E represents one time of defecation after enema. Document the number of times once a day
Fluid intake and output • Document the total amount of Fluid intake and output of the previous day (during a 24-hour period) according to the physician's order. • the amount of intake and output fluids are recorded in ml. Fluid output Fluid Intake
Blood Pressure Readings of blood pressure are recorded in corresponding time columns. If more measuring is needed, the readings of measurement can be recorded in the nursing notes. 110/75, 105/70
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.
days of operation (childbirth) The next day 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
Days of hospitalization write in Arabic number“1, 2, 3...” from the day of admission to the day of discharge.
Page
Number • Fill the page numbers in sequence.
Managing Physician’s 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)
∨ ∨ ∨ physician order recording book 医 嘱 本 山东大学齐鲁医院 床号 姓名 时间 医嘱 医生 执行 护士 签名 时间 签名 2007-12-11 1-3 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（ ）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 2007-12-12 1-3 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
physician order sheet STAT order Sheet Standing order Sheet
various types of forms that are necessary for implementation
• nursing grade sheet • diet sheet • oral medication sheet • injection sheet • treatment sheet, etc. 口服药 1-3 张利 8 –12 – 4 Vc 100mg 土霉素 0.5 8pm 土霉素 0.5
Contents of Physician Order • Date, Time, • Bed No, Name • medication (name, dosage, routes of administration); • pre-operation preparation; • diagnostic Study and
therapy, preparation for diagnostic test or surgery • routine care • grade of nursing • diet • body position • physician's signature • nurse's signature
Types of Physician Order • Standing Order • STAT Order • PRN Order • SOS Order
Standing Order • A standing order is valid until it is cancelled by the physician. Usually the valid time of a standing order exceeds 24 hours.
STAT Order 安定 5mg hs. • The valid time limit of a STAT orderis within 24 hours, usually
only once. • Sometimes a STAT (ST) order signifies that a single dose of medication is to be given immediately.
Good record keeping is a fundamental part of delivering safe patient care. An accurate written record detailing all aspects of patient monitoring is important because it contributes to the circulation of information amongst the different teams involved in the patient's treatment or care.
