General shift to-point record of real-time recording disease.docVIP

 PAGE \* MERGEFORMAT 11 General shift to-point record of real-time recording disease Study: Single Zou Dongmei Cai Yan Chen Weiling [Abstract] In order to explore a suitable situation and meet the legal requirements of nursing illness records, the current implementation of point-real-time hospital nursing records, by year, the practice shows that the improved conditions of care record is practical nursing work can observed changes in condition, treatment measures of effect evaluation record anytime, anywhere, are not subject to frequency, time constraints, the use of multiple time points by the time the order in a timely manner, the real record, can fully reflect the care and strengthen the work of nurses sense of responsibility to improve the quality of care, strengthen the legal effect, but also simplify the care and medical records, reducing the time shift nurses writing, is an effective method of writing. [Keywords:] nursing program nursing shift illness records Patient care and medical condition documented record is an important part in its records the whole process of treatment and care of patients, anti-evolution film of the patient’s condition, to ensure the safety of patients has important legal effect [1]. The current I Ministry of Health hospital in order to meet the requirements of nursing documentation writing objective, true, timely, accurate, complete, by year of practice, shows that the improved condition of nursing records with the practical, are the three areas of the kidney following the implementation of reform report shift for colleagues explore. to talk about the past record of the old shift pattern: 1, the defects of traditional nursing illness records 1.1 The record of repetitive, dispersion, wasteful Each patient after admission, such as general good, with general nursing record sheet, the class should write, “patients with the spirit of good, good appetite, breathing smoothly, without a special appeal is not” lim