護(hù)理 英文 整理 護(hù)理文件書(shū)寫(xiě)ppt課件

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Chapter16NursingDocumentation，medicalandnursingdocuments，clientsrecord， aclientsmedicalrecordtemperatureshephysiciansordersheetspecialnusingrecordchart，etc .Change-of-shiftreport . section1recordicandadmicalandnursingdocuments，purpoposefrecords，PrincipleofRecords，admicalandnursingdocuments.purposeofrecords providingdataforeductionandresearch，PrinciplesofRecords， folowthospitalsrequirementtomodocumentationatrularintervals .norecordingshouldbedebeoreproidingnusingcares， anddloringingoromittingtherecordingisnotacceptableeither .recordingmustbeaccurateandccorrect . autratrerecodentsistoffactobserverationsratherthanopinionsorinterpretation .Theclientsname，age， andbednumber shouldbewrittenoneachpageoftherecord .leavingnoblanklineontheclientchart . thecareververustitussishsorherfullnameaferrecording.alcientsconditioniscritical.aliientinsistesonrefusingatreatmentorleavingth cal advice.aliienthasinclinationofcommittingsuicide .thesesstiturationsmustbefilledintheclentschart .Documentationmustbeconcise andlaystressonkeypoints .allentriesmustbelegibreleandeasytoread.whewernarecordingerrorismade， drawalinethroughitandwritethecorrectorsnameaboveit.do not erase，blotout orusecorrectionfluid .admistricationofmedicalandnursing admistricationrequirements，arrangementorderedmedicalrecord， administrationrequirements . allmedicallandnurrnusingdocumentshoulldbepacedftbepacedberentberingdrecordered . medicalandnursingdocumentsmstbekeptneatly，orderly，completelingdpdeventtthemfrombeingecontamidinated，mangled，disconnectedandlost theclitentortheclientsfamillyshouldnotreadthemedicalandlnusingdocumentsfrree.nocarryingthedocumentsoutofftheforwardwithoutbein eedt obecarriedoutoftheforwardforthepurpposeofmedicalactivityorcopy，itshouldbecarriedandeptwellbyhospitallappointedstatff . allthedocumentsshouldbekeptproperly.whentheclientisdischargdforomtheshospital， temperature sheet physiciansordersheetandspeciallnorrsingrecordcharthithehoshitallsherecordicrecolldirecordingroumofthehoshoshii ekeptatleasteyearattheforwardlevel .arrangementorderedmedicalrecord，ordopoptimissisonrecord，orderofdischarge orderedofadmissionrecord temperaturesheetphysiciansordershiteddimissonsheterdrecordmicralisstorandpdisicialingphiciationansree co rtspresspecationlurngrecorrdfirstpageofclientrecordsonshetoutpatientrecord .OrderofDischarge(transfer， death ) record firstpageofclientrecordadmissionsheet (ifclientdied ) addingdeathreportsheet dischargeordeathrecordsadmissonionrecordiclectricalshonddpisicialingphyicansreconsconstationrecontricationdicationscre physicial uresheetoutpatientrecordisgivenbacktotheclientntsfamily .section2writingnursingdocuments， temperature sheet.managing physicians order，recordingrespecificialnusing，reporting clientsconditions，中國(guó)醫(yī)療信息化的發(fā)展，醫(yī)院信息系統(tǒng)(hospitalinfo ) HIS )面向臨床的醫(yī)院臨床信息系統(tǒng)(clinicalinformationsystem，CIS )將成為HIS的重要發(fā)展方向。 CIS包括電子病歷系統(tǒng)、醫(yī)學(xué)圖像處理系統(tǒng)、實(shí)驗(yàn)室數(shù)據(jù)處理系統(tǒng)、臨床專(zhuān)業(yè)數(shù)據(jù)分析系統(tǒng)等。. temperature sheet itisonthefirstpageofclientshospilizationrecord.itprovidesshetafwithquicksummaryofallhathestriticonditionandvid ，F(xiàn)illinginTopPart，thispristmustebefilldinwithabue-blackinkdorcarboninkdpen.clients name，sex，age， ward admissiondetandhoshitializationnumbermustebefeverypage .year，monthanddmycustebefedfertheftdacolumnofeverypage .therestsixx filling in between 40 42colnoftemperaturesheet，Timeofadmission，operation，childbirth， transfer dischargeordeathisfillingthevitureconfilentheviternecorrespondingimecolumnihitharedpenbetween 40 42column.itissessentt inute.ifthetimeisnoteq univatttteimattemperaturesheet，fillintheproximaltimecolumn .prodingboditymperturraturrecurredawing prodingboditymperaturre oral temperature : 、Axillarytemperature、rectaltemperature， twoutodeconterationadissereconnectedbyblueeline . alitintwhypryrexienedstohhethehithebodmetratertachinginfarfanhoufferreceiving adingofmeasuredtemperatureisdrawinthesame longitdinalcolumnofpreviousreadingbyred“”andconnectedwiththereadingbeforephysicalthe dingofnexismementsillconnedwiththereadingbeforephysicaltherapy .aclientsbodytempreratureisbelow 35，不上升，不上升， redingofsemationedtemperatersrepresentedbyblue，andconnectedwiththeadjcentradings .DrawingSphygmogram，pulserateisdrawninre twocorresspoingredingsofspleaterateconnedbyredline . pulse deficit heatrateisinred twoocorresposindingredingsoftheratrareeconnectredbyredline.filedintareatebewetheentheneoppera 、ifthereadingofbodytempreratureandpulseserateareatthesamepoint、drawthetemperaturefirstinblue thendrawaredcircle () outsidetheblue“torepresentthepulserate .Respiration， redingsofsofrepiciationarrecorredicnorrespondingimecolumnsinarabicnumberwithblueepennandthenumberrsarewrittenalativelyus FillinginBottomPart，allothispartisfilledbuer-blackinkdorcarboninkedpen.arabicnumberedpentsthereadings.calculationunitisomited 、BowelMovement、documentthemboowelmovementonthepreviousday.ifthereisnobowmovement、document0； fecalicalconntinenceisdocumentedas ； “E”representsenema.(0/E； 11/E )、documentthenumberroftmesonceaday、1/erpressessentityofdefecationafterenema .， fluidintakeandoutput documentthetotalamountofuidintakeandoutfthepreviousday (du