Jiangsu issues and simplifies and attends to and records and writes the opinion

Jiangsu issues and simplifies and attends to and records and writes the opinion
Jiangsu issues and simplifies and attends to and records and writes the opinion
It is reported ' The intersection of reporter and old little the intersection of army and Yang beautiful and good) The department of public health of Jiangsu Province issues and simplifies to a nurse and writes implementation suggestion on March 31, the ones that demand to attend to recording are simplified and needing to observe the following principles: First, judge according to the needs of patient's condition when to write and attend to recording to master, can't machinery " only interpreted as when the doctor assigned critically ill, seriously ill doctor's order ; Medicine, protect, record, accomplish complementary unifying. Opinion point out, combine nursing on reality is can simple record, include: The general patient's nursing record; Every one of long-term doctor's order is carried out, does not set up " the doctor's order is carried out singly " separately again Carry on the record; Teaching, record that the quality accused of, to the nursing record form (accuse of various forms of the means out of teaching purpose or quality) not filing Should control strictly, attend to big case history, attend to, assess single handing over, recording single, etc wholly; Attend to and manage the document. Head nurse manage document need be limited to to plan and summarized ' Annual /moon) , arrange an order according to class and grade, record, attend to quality accuse of, record, attend to, make the rounds of the wards, record and vocational study record and performance examine the record.


|