整体护理讲座-山东大学.PPT

Chapter 16 Nursing Documentation medical and nursing documents Section 1 Record and Administration of medical and Nursing Documents Purpose of Records Purpose of Records Principles of Records follow the hospital’s requirement to make documentation at regular intervals. Recording must be accurate and correct. The clients name, age, and bed number, should be written on each page of the record. All entries must be legible and easy to read. When a recording error is made, draw a line through it and write the correctors name above it. Do not erase, blot out, or use correction fluid. Administration of Medical and Nursing Documents Administration Requirements Administration Requirements Arrangement Order of Medical Record Order of Admission Record Order of Admission Record Temperature sheet Physician’s order sheet Admission sheet and record medical history and physical examination Physicians record Consultation record Diagnostic studies reports Special nursing record First page of client record Admission sheet Outpatient record Order of Discharge (transfer, death) Record First page of client record Admission sheet (if client died, adding death report sheet) Discharge or death record Admission record medical history and physical examination Physicians record Consultation record Diagnostic studies reports special nursing record Physician’s order sheet Temperature sheet Outpatient record is given back to the client or the clients family. Section 2 Writing Nursing Documents Temperature Sheet 中国医疗信息化的发展 医院信息系 统(hospital information system, HIS) 面向临床工作的医院临 床信息系统( clinical information system, CIS)将成为HIS的重点发展方向。CIS包括电子病历系统、医学影像处理系统、实验室数据处理系统、临床专科数据分析系统等。 Temperature Sheet It is on the first page of clients hospitalization record. it provides the staff with a quick summary of all the clients condition and vital signs on the sheet. Filling in Top Part This part must be filled in with a blue-black inked or carbon inked pen . Clients name, sex,