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1、安徽省护理文书书写要求（Requirement of nursing document writing in Anhui）Anhui nursing document writing request! Reprinted from heartbreak Utopia. Reprinted in 2010, 06, 30, 23:39, read (5) comment (0)Category: personal diary ReportSection 1 basic requirements1. the writing of nursing documents should be object
2、ive, truthful, accurate, timely and complete.2. nursing documentation should use black ink, record must sign. The nursing documents written by the nurses who have been engaged in practice, further studies and those who have not obtained the practice permit shall be reviewed immediately by the legal
3、nurses designated by the medical institution, and their revised opinions and signatures shall be written in red ink pens.3. nursing documents should be written neatly, clearly written, accurate expression, punctuation marks applied correctly.4. typo in the writing process, should use the double line
4、s painted on the typo (record himself with a blue black stroke double lines, modified with red ink strokes, and correct the double lines), shall not take scraping, viscosity, coating, stickers and other methods to conceal or erase the original handwriting.5. cases should be written in Arabia digital
5、 writing date and time, using 24 hour system record.6. nurses need to fill in or write the nursing documents, including: temperature list, medical orders, records of the course of surgery, inventory records and critical care records.Second temperature sheets1. temperature table format, including: we
6、ek number, date of admission, hospitalization days, hospitalization days after operation, body temperature, pulse, respiration, blood pressure, stool frequency, and liquid volume, weight, drug allergy and patient records the lintel column.2. in blue or black ink pen to fill out the lintel column of
7、the name, date of admission, Department, bed, hospital number, date of hospitalization and hospitalization. The date of hospitalization, the first day of the home page and the first day of the next year should be written in years, months and days. The first day of each thermometer and the first day
8、of the month should be written on the month and the day, and the rest will only be filled.Fill in the number of days after the operation with red ink. The day after the operation (first days after the operation) is filled up until 14 days. The second operation in writing date column, fill in the num
9、ber of days after surgery. If the second operation is performed within 14 days after the first operation, draw a slash at the end of the first day of operation and fill in II. For example, after the operation: 12345 / 6 / 7 l II / 28 / 39 / 4 (in red ink).3. in 40 42 degrees corresponding to the tim
10、e column, with the red ink pen was filling out the admission or death time and operation, delivery, transfer and discharge, automatic discharge etc. Transfer completed by the Department to transfer, or bed, to fill in the new department and bed in the back section, bed number column, and brackets.4.
11、 newly admitted patients measure their body temperature, pulse and respiration 2 times daily (7Am, 3Pm). For 3 consecutive days, patients with normal temperature measure their body temperature, pulse and respiration 1 times a day (3Pm). The temperature reached 37.5 degrees and above, major surgery,
12、critically ill patients daily measured body temperature, pulse, breathing 3 times (7Am, 3Pm, 7Pm); the temperature reached 38.5 degrees and above, every 4 hours to measure temperature, pulse, breathing 1 times (at least 5 times a day, if the temperature is below 38.5 DEG 11Pm, 3Am can not measure),
13、the temperature dropped to 38.5 degrees Celsius to 3 consecutive days the daily measured body temperature, pulse, breathing 3 times, returned to normal after 3 days to 1 times a day. Subject to physical or medicinal hypothermia, the body temperature reaches 38.5 degrees and above.5. the drawing of b
14、ody temperature, pulse and respiration diagram:(1) drawing the body temperature curve:The thermometer is painted on the thermometer with a blue pen. The temperature of the mouth is expressed by X, and the anal temperature is expressed by O. The two body temperature is connected with the blue line.Th
15、e physical cooling or drug cooling after half an hour, the temperature of painting in the physical cooling of the same longitudinal grid, with a red O, and with a red dotted line, the next time the temperature should be connected with the cooling temperature. After cooling down, if the body temperat
16、ure does not drop or rise, the body temperature can not be drawn and recorded in the nursing record.When the body temperature does not rise, below 35 centigrade, mark the temperature mark at the 35 centigrade line.The reason why patients due to medical activities, to test out without measurement of body temperature, 34 degrees in the line below the corresponding time column in blue or black ink pen
