Chapter 16
Nursing Documentation
medical and nursing documents
A client's medical record
client's record
Temperature sheet
Physician’s order sheet
special nursing record chart , etc.
Change-of-shift report (病室交班报告)
Section 1 Record and Administration
of medical and Nursing Documents
Purpose of Records
Principle of Records
Administration of Medical and Nursing
Documents
Purpose of Records
Providing Information
Providing Data for Education and Research
Providing Basis for Quality Review
Providing Basis for Legal Purpose
Principles of Records
1
2
3
4
5
Timely
Objective and Accurate
Complete
Concise
Legible
1
Timely
• follow the hospital’s requirement
to make documentation at regular
intervals.
•No recording should be done before
providing nursing cares, and
delaying or omitting the recording is
not acceptable either.
2
Objective and Accurate
Recording must be accurate and correct.
Accurate recordings consist of facts
or observations rather than opinions
or interpretation.
3
Complete
• The client's name, age, and bed number, should be written
on each page of the record.
•Leaving no blank lines on the client's chart.
•the caregiver must sign his or her full name after recording.
•a client's condition is critical.
• a client insists on refusing a treatment or
leaving the hospital against medical advice.
•a client has inclination of committing suicide.
these situations must
be filled in the client's
chart.
4
Concise
Documentation must be concise,
in a logical order, and lay stress
on key points.
5
Legible
• All entries must be legible and easy to read.
• When a recording error is made, draw a line
through it and write the corrector's name
above it.
• Do not erase, blot out, or use correction fluid.
Administration of
Medical and Nursing Documents
Administration Requirements
Arrangement Order of Medical Record
Administration Requirements
All medical and nursing documents should be
placed according to organization guidelines.
They should be replaced after being read or
recorded.
Medical and nursing documents must be kept
neatly, orderly, completely and prevent them from
being contaminated, mangled, disconnected and
lost.
The client or the client's family should not read the
medical and nursing documents freely.
No carrying the documents out of the ward without being
permitted.
If the documents need to be carried out of the ward for the
purpose of medical activity or copy, it should be carried and
kept well by hospital appointed staff.
All the documents should be kept properly.
When the client is discharged from the hospital,
temperature sheet, physician’s order sheet and special
nursing record chart will be kept permanently in Medical
Recording Room of the hospital as parts of the client's casenotes.
The change-of-shift report will be kept at least one year at
the ward level.
Arrangement Order of Medical Record
Order of Admission Record
Order of Discharge (transfer, death) Record
Order of Admission Record
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•
•
•
•
•
•
•
•
•
•
Temperature sheet
Physician’s order sheet
Admission sheet and record
medical history and physical examination
Physician's 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
Physician's 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 client's
family.
Section 2 Writing Nursing Documents
Temperature Sheet
Managing Physician’s Order
Recording Special nursing
Reporting Client’s Conditions
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 client's
hospitalization record.
 it provides the staff
with a quick
summary of all the
client's 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 .
 Client's name, sex, age, ward, admission date and
hospitalization number must be filled in completely.
year, month and day must be
filled in the first day column
of every page.
the rest six days column only “Day”
Filling in Between 40℃~42℃
Column of Temperature Sheet
Time of admission, operation, childbirth, transfer,discharge
or death is filled in the vertical line of corresponding time
column with a red inked pen between 40 ℃~42℃ column. it is
essential to specify the minute. If the time is not equal to the
time at temperature sheet, fill in the proximal time column.
Drawing Body Temperature Curve
Drawing Sphygmogram
Drawing Body Temperature Curve
 Oral temperature :“●”，
 Axillary temperature “×，
 Rectal temperature “○”.
Two adjacent readings are connected by blue line.
• A client with hyperpyrexia needs to have the body
temperature taken again in half an hour after receiving
physical therapy.The reading of measured temperature is
drawn in the same longitudinal column of previous reading
by red “○”, and connected with the reading before
physical therapy by red dotted line. The reading of next
measurement is still connected with the reading before
physical therapy.
a client's body temperature is below 35℃
不
升
不
升
Reading of measured temperature is represented by blue
“×”, and connected with the adjacent readings.
Drawing Sphygmogram
 Pulse rate is drawn in red “ ● ”,Two corresponding
readings of pulse rate are connected by red line.
pulse deficit
 heart rate is in red “○”. Two corresponding readings of
heart rate are connected by red line.
 filled in the area between the line of pulse rate and the line
of heart rate in red line.
 If the reading of body temperature and pulse rate are at
the same point, draw the temperature first in blue “×” ,
then draw a red circle( ○ ) outside the blue “ × ” to
represent the pulse rate.
Respiration
Readings of respiration are recorded in corresponding time
columns in Arabic number with blue pen and the numbers
are written alternatively upward and downward.
Filling in Bottom Part
All this part is filled in by using a blue-black inked or
carbon inked pen. Arabic number represents the readings.
Calculation unit is omitted. Contents：
Bowel Movement
Document the bowel movement on the previous day. If
there is no bowel movement, document "0"; fecal incontinence
is documented as "※"; “ E” represents enema. (0/E ; 11/E)
Document the number
of times once a day
1 /E represents one time
of defecation after enema.
Fluid intake and output
Fluid output
Fluid Intake
•
Document the total amount of Fluid intake and output of
the previous day (during a 24-hour period) according to the
physician's order.
• the amount of intake and output fluids are recorded in ml.
Blood Pressure
Readings of blood pressure are recorded in
corresponding time columns.
110/75, 105/70
If more measuring is needed, the readings of measurement
can be recorded in the nursing notes.
Body Weight
 Fill it in the unit of kg. When a client is admitted, the nurse
measures his or her body weight and documents it in the
corresponding time column.
 During hospitalization, measure and document body
weight once a week.
days of operation (childbirth)
The next day of operation (childbirth) is regarded as the
first day of operation (childbirth) that has been charted
continuously on the day column in Arabic number “1, 2,
3... ” until 10 days.
If a second operation has
been done within 10 days
Days of hospitalization
write in Arabic number“1, 2, 3...” from the day of
admission to the day of discharge.
Page Number
• Fill the page numbers in sequence.
Managing Physician’s Order
 physician order recording book( 医嘱本)
physician order sheet(医嘱单)
various types of forms that are
necessary for implementation (各种执行单)
∨
∨
∨
physician order recording book
床号 姓名 时间
医嘱
医生 执行 护士
签名 时间 签名
2007-12-11
1-3 张利 8am 外科护理常规
马良
李 玲
Ⅱ级护理
流质饮食
青霉素皮试（ ）st
8am 黄华
10%GS500ml
青霉素640万u ivdrip qd
丁 胺卡那 0.2 im bid
Vc 100mg tid
氧气吸入 p r n
李玲
2007-12-12
1-3 张利 4pm 停Vc 100mg tid
下午2点胸腔穿刺
安定 5mg hs
度冷丁 50mg im q6h
李玲
2pm 吕新
李玲
医 嘱 本
山东大学齐鲁医院
physician order sheet
STAT order Sheet
Standing order Sheet
various types of forms
that are necessary for implementation
•
•
•
•
•
nursing grade sheet
diet sheet
oral medication sheet
injection sheet
treatment sheet, etc.
口服药
1-3
张利
8 –12 – 4
Vc 100mg
土霉素 0.5
8pm
土霉素 0.5
Contents of Physician Order
• Date, Time,
• Bed No, Name
• routine care
• grade of nursing
• diet
• body position
• physician's signature
• nurse's signature
• medication (name, dosage,
routes of administration);
• pre-operation preparation;
• diagnostic Study and therapy,
preparation for diagnostic test
or surgery
Types of Physician Order
•
•
•
•
Standing Order
STAT Order
PRN Order
SOS Order
Standing Order
• A standing order
is valid until it is cancelled by the physician.
Usually the valid time of a standing order exceeds 24
hours.
STAT Order
安定 5mg hs.
• The valid time limit of a STAT order is
within 24 hours, usually only once.
• Sometimes a STAT (ST) order signifies
that a single dose of medication is to be
given immediately.
PRN Order
• PRN order is a kind of standing order.
• The physician may order a treatment on a PRN
basis if the client's condition needs.
• Often the physician sets minimal intervals between
two times of administration.
度冷丁 50mg im q6h prn
SOS Order
• The valid time of the SOS order is within 12 hours.
• It will be carried out only once as the state of an
illness needs.
• It becomes invalid if it exceeds the time limit.
Managing Physician Order
• Method of Handling
•Principles of Managing
Standing Order
• transfers the orders onto various types of
forms.
• The standing orders transferred onto the
implementation forms which are carried out
in appointed time should be signed specific
administered time.
PRN order
transfers them onto various types of forms.
If the physician sets minimal intervals
between two times of administration, each
time the nurse carries out the PRN order, he
or she has to document the exact time and
sign full name.
STAT Order
• “st” means executing an order immediately.
• After carrying out the order, the nurse has
to sign his or her name in “executer”
column and notes the time of executing.
penicillin skin test
penicillin
positive (＋)
negative (－)
SOS order
• SOS order should be carried out only once as the
state of an illness needs.
• The person, who carries out the order, signs his or
her name in “performer” column and notes the
time of executing.
• The order becomes invalid if it exceeds the time
limit. The nurse writes the word “unexecuted”,
documents the time and signs her name.
Stop the Order
• If a physician decides to stop an order for
some reasons, the nurse cancels the order in
related treatment sheet first.
• write down the date and time in “stop”
column in physician order sheet.
Re-arranging the Order
• draw a red line below the last row of physician orders,
write “Rearranging” in the middle below the red line with
a red pen, and transcribe original valid physician orders
onto spaces below the red line.
• Two nurses verify the rearranged orders and sign their
names.
• After the operation, childbirth or transferring, physician
orders have to be rearranged too. Draw a red line below
the last row of original orders, and write “post-operation
order”, “post-childbirth order”,
•Principles of Managing
• Urgent Before Routine.
When managing several physician orders,
it is necessary to see which order is more
important or urgent to the client, and give
priority for carrying it out.
•Principles of Managing
STAT Order Before Standing Order.
• It is routine to carry out a STAT order before a
standing one.
•Principles of Managing
• The order could not be changed. If it is to be
canceled, note “cancel” with a red pen and
sign.
•Principles of Managing
• Generally speaking, the physician should not give
oral orders. In the events of an emergency or
during operation when the physician gives orders
orally to nurses, the nurses have to repeat the
order once again and make sure it is correct.
• After the emergency has been allayed and the
physician should record and sign all orders that
were given.
•Principles of Managing
• If a STAT or SOS order is to be carried out
on the next shift, the order should be written
down in the nursing notes.
•Principles of Managing
• The physician orders must be checked in
every shift and totally once every week.
clinical information system, CIS
医嘱处理
医生登录医生工作站系统,将医嘱按照长期医嘱、
临时医嘱、辅助检查、化验等分类 录入系统, 护士
登录护士工作站系统进行处理:
• 审核医嘱
• 执行医嘱
• 打印表单和医嘱单
Recording Fluid Intake and Output
• Contents
• Methods for Recording
Contents
fluid intake
出入液量记录单
•oral fluid intake
•food intake
•intravenous fluid
infusions
fluid output
urine, stool, vomit,
bleeding, sputum,
gastric suction, and
drainage from postsurgical drainage tubes.
Methods for Recording
• Daytime's fluid intake and output are recorded
with a blue-black inked or carbon inked pen;
• nighttime's fluid intake and output are recorded
with a red pen.
• intake and output are summarized at the end of
each 12-hour and 24-hour period. Sum of intake
and output of 24-hour period is filled in
corresponding column of the temperature sheet.
Recording Special Nursing
• Contents of record
• Methods and Recommendations
for Recording
Contents of record
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vital signs
level of consciousness
fluid intake and output
state of illness
nursing intervention
response to medication
signature
Methods and Recommendations
特别护理记录单
Change-of-shift report
Components of Report
Recommendations
Components of Report
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Discharge, Transfer-out, and Death Report
Admission, Transfer-in Report
Severely Ill Clients' Report
Postoperative Clients' Report
Pre-operation, pre-diagnostic Studies Preparation
Report
Ward
Top Part
date
time
total number of clients
number of client
admission
discharge
transfer
Operation
childbirth
clients in critical state
death.
discharge, transfer-out, death
admission, transfer-in
Order of Writing
operative clients, clients who gives birth,
critically ill clients, and clients of
unusual condition
病人情况日夜报告
护士长签字：
日期—年—月—日
姓名
床号
诊断
入院
出院
转出
病重
手术
死亡
同左
3床 杜鹃
甲状腺瘤住院10天治愈于9am出院
5床 许威
胃癌住院14天于4pm转普外科
19 床
T
P
R
at 4pm
庞月
患者
上消化道穿
孔并腹膜炎
新
31床
吴军
肺癌
手术
T
P
R
T
P
患者
同左
R
at
T
P
患者
R
at
at
护理要点：1、
护士签名
护士签名
护士签名
Recommendations
• Record is on the basis of sound observation.
• The report should be concise, accurate and
objective, and highlight important points.
• The report should be neat and legible. Do not
erase.
• Daytime's conditions are recorded with a blue pen,
and nighttime's conditions are recorded with a red
pen.
• Entries are filled in the following orders:
 write down the bed number
 name and diagnosis
 vital signs and the time of measuring
 the clients' conditions, treatment and nursing care
provided
• For clients newly admitted, transferred-in,
having operation or childbirth, write down
the word “New”, “Transfer”, “Operation”,
and “Childbirth” in red under the words of
diagnosis. For severely ill clients, it is
highlighted by the symbol “※”, or the word
“critically ill” in red.
• After finishing the recording, write down
the number of pages and sign full name.
• The head nurse should check the client's
condition report of each shift and make sure
it meets the nursing quality criteria, then
sign her full name.