护理文书 文本文档（Nursing document document）.docVIP

护理文书 文本文档（Nursing document document） According to the Ministry of health on the issuance of basic norms of medical records of the notice (Wei Yi Fa No. [2010]11) and on the strengthening of clinical nursing work notice (Wei Yi Fa No. [2010]7) requirements, at the same time to strengthen the basic nursing, implement the nursing shift system, ensure the safety of patients, nurses need nursing documents fill or writing including surgery single temperature, single doctor, course record inventory records and ill (dying) nursing records and nursing care of patients with night shift report. The basic requirements for nursing document writing and doctors instructions are hereby stipulated as follows: I. temperature list (form see attachment 1) A single temperature is used to record the patients body temperature, pulse, respiration and other conditions, including patients name, Department, date of admission, hospitalization record (or record number), date, days after operation, body temperature, pulse, respiration, blood pressure, stool frequency, and liquid volume, weight, number of weeks of hospitalization. Mainly completed by the nurse, during hospitalization, the temperature list is arranged in front of the medical record. One tone writing requirement 1. temperature Eyebrow Bar items, date and number of pages are in blue or black, carbon ink pen. Each item should be completed and legible. The square between 2. in 40 to 42 DEG C temperature vertical fill in the project delivery, hospitalization, surgery, transferred and transferring and discharge, death and leave with a red pen. 3. each day of the thermometer shall be completed on first days, months and days, and the remaining 6 days shall not be filled in years, months, and days only. If the month or year is crossed in this page, the month, day or year, month and day should be completed. 4. temperature 34 degrees below the columns, filled with blue, carbon ink pen. 5. days after completing 10 days of continuous operation