Psychiatric nursing records frequently asked questions and responses.doc

Psychiatric nursing records frequently asked questions and responses [Keywords:] the spirit of With the September 2002 the new ‘medical treatment regulations’ promulgation and implementation of nursing as an objective data files are an important component of health care in the event of disputes, and the family can always copy and reproduction of objective information on the medical unit to ‘Juzhengdaozhi’ an important basis for the care record is under doctor’s orders and the conditions of nurses to patients during hospitalization for an objective record of the nursing process, nurses need to be objective records, accurate, truthful, timely, complete, focused and structured. As the special nature of psychiatric patients, one non-family company, and two are mentally ill due to psychiatric symptoms cause trouble, there is no proper complaint, requiring close clinical observation of nurses, the patient’s condition, treatment and care are correct in the nursing records reflected. In the implementation of the work, records of psychiatric care that there are many problems. Is against me in the hospital records of psychiatric care and common problems and take measures reported as follows. A Frequently Asked Questions 1.1 for the first time the vital signs nursing records do not fully account for is unclear, such as writing a normal vital signs, or body temperature alone does not match; due to incomplete medical care, such as skin integrity confessed unclear, the patient’s teeth, fingers, toes and other shortcomings is not to write Qing; Sometimes, because of time constraints, on doctor’s orders did not justify the next one on the admission of special care and measures have been taken by Xie Qing; and even have a care record is written in the handwriting of two nurses. 1.2 Ban Class records in our hospital three days of the new patients admitted to classes in records and found that often Youlou in mind, and sometimes because of carelessness, nursing records wrongly