护理记录书写(国外英语资料).docVIP

护理记录书写(国外英语资料) Nursing records is a nurse in the process of medical care activities reflect the patient vital signs, the embodiment of all medical measures to carry out the situation and records of the results. Nursing records, can not only reaction hospital medical care quality, academic and management level, and for medical treatment, teaching, scientific research provide valuable basic data, when involved in medical dispute is also the important proof material, is the important basis for determining the legal responsibility. But, for a long time, due to the traditional biomedical model, the influence of the functional system of nursing, the nursing record is not standard, the content of the quality assurance of nursing records. The following authors summarize the research data on nursing records as follows for their reference. The meaning of writing a nursing record Nursing records is an important part of medical care file, it reflects the patients hospitalized in sick of all the medical care during the study, embodies the connotation of nursing work, clinical teaching and scientific research is an important and indispensable material, with a strong force of law. Nursing record strengthened the relationship between the medical communication, improve the nurses observation, communication, writing and so on various aspects ability, strengthens the sense of responsibility, improve the nursing quality. The care record writes the content 2.1 admission assessment after patients admitted to hospital nurses by talking to family members or relatives history, body and illness for nursing observation, reading outpatient records and test results, with the patients disease related information collection. These data mainly includes: (1) the patients general condition: such as name, gender, age, occupation, nationality, marriage, culture degree, time, hospital admission. (2) to be hospitalized and to collect data. (3) the nursing charge, such as body temperature, pulse, respira