护理文书书写规范及要求 - 修改本

护理文书书写规范及要求 - 修改本 护理病历书写规范总则 新规范指导思想 , 摒弃“无用功” , 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 格式护理文书 , 医护记录互补、统一 , 留有一定余地 , 专科护理记录单 护士全面减负 , 把时间还给护士,把护士还给病人 内容结构 1、基本要求 2、体温单填画要求 3、医嘱单记录要求 4、病危(病重)患者护理记录要求 5、手术清点记录要求 一、 基本要求 根据卫生部《病历书写基本规范(2010)》及《卫生部办公厅关于在医疗机构推行表格式护理文书的通知》(卫办医政发[2010]125号)文件要求《和田人民地区医院护理文书书写要求》(第一版)制定本规范。 1.护士需要填写、书写的护理文书包括:体温单、医嘱单、病危(病重)患者护理记录单、手术清点记录单。 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 2.护理文书一律使用蓝黑墨水笔书写。 3.护理文书一律使用阿拉伯数字书写日期和时间、日期用年,月,日，时间采用24小时制，具体到分钟。 4.护理文书记录内容应当客观、真实、准确、及时、规范。 5.书写应当使用中文、医学术语和通用的外文缩写，文字工整，字迹清晰，表述准确，语句通顺，标点正确。 6.书写过程中出现错字时，用双横线划在错字上，保留原记录清楚、可辨，并注明修改时间，修改人签名。不得采用刮、粘、涂等方法掩盖或去除原来的字迹。上级护理人员有审查修改下级护理人员书写记录的责任。修改时用并蓝黑墨水笔修改签名及时间。每页版面修改次数不超过两处，否则由原来笔迹者重抄。 7.实习护士、试用期护士、未取得护士资格证书或未经注册护士书写的护理记录，应由本医疗机构具有合法执业资格的护士审阅并签名及时间。 8.进修护士由接受进修的医疗机构认定其工作能力后方可书写护理文书。 二、体温单填画要求 1.体温单项目分为楣栏、一般项目栏、生命体征绘制栏、特殊项目栏。 2.各项目栏除特殊要求和说明外，均应使用同色笔书写。 3.数字除特殊说明外，均使用阿拉伯数字表述，不书写计量单位。 4.体温单填写、绘画过程中出现错误时应重新书写。 5.补充项目栏:记录患者住院期间特殊治疗、血压、体重、出入量、tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 和田地区人民医院 管理制度 档案管理制度下载食品安全管理制度下载三类维修管理制度下载财务管理制度免费下载安全设施管理制度下载 编码:ZD/HL-A074 第 3 页 共 13 页 大便次数、住院周数等。 二、填写说明 1.楣栏项目包括:科室、床号、姓名、性别、年龄、住院病历号(或病案号)、入院日期，均使用正楷字体书写。 2.一般项目栏包括:日期、住院天数、手术后天数等 (1)日期:住院日期首页第1日及跨年度第1日需填写年-月-日。每页体温单的第1日及跨月的第1日需填写月-日， 其余只填写日期。 (2)住院天数:自入院当日开始计数，直至出院。 (3)手术后天数:患者手术当日有手术日记录，自手术次日开始计数，连续书写14天。若在14天内进行第2次手术，则将第1次手术天数作为分母，第2次手术天数作为分子填写， 第三次手术以此类推，每次手术填满14日止。 14日止 第三次手术以此类推，每次手术填满14日止。本次住院期间多次手术者应有明确标识记录。 3.生命体征绘制栏:包括体温、脉搏描记及呼吸记录区。 (1)体温 ?40?,42?之间的记录:用蓝色水笔在40?,42?之间以正楷汉字纵向顶格填写患者入院(急诊手术入院)、转入、手术、分娩、出院、死亡等。除手术不写具体时间外，其余均按24小时制，精确到分钟，转入时间由转入科室填写，书写可超过40?。急诊手术住院患者入院时间从患者进入手术室时间算起，其他患者入院时间从到达病房办理住院程序时间算起。 ?体温符号:口温以蓝“?”表示，腋温以蓝“×”表示，肛温以蓝tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe “?”表示。 ?每小格为0.2?，按实际测量度数，用蓝色笔绘制于体温单35?,42?之间，相邻温度用蓝直线相连。新入院患者体温超过 40?，仍画在相应位置。 ?体温不升时，可将“不升”二字写在35?线以下 ?物理降温30分钟后、药物降温30分钟后至两小时内测量的体温以红圈“?”表示，画在降温前温度的同一纵格内，以红虚线(下降)或红直线(上升)与降温前温度相连，体温无变化时在降温前温度外画红“?”表示。 ?一般住院患者每天测量体温、脉搏、呼吸1次，发热、手术、病危(病重)、感染性疾病等患者按医嘱或专科护理常规处理。住院病人体温在37、5?以下时，每日测量一次，如体温在37、5?以上(含37、5?)，每日测量四次，如体温超过38、5?(含38、5?)，每日测量六次。体温降至正常，三天后改为每日一次。新入院病人当日测四次体温后改为每日一次。如体温异常，应根据体温情况按上述要求测量。 ?患者拒绝测体温、蓝色“?”表示，擅自离院时在体温单35?横线下写外出，前后之间不连线。 (2)脉搏 ?脉搏符号:以红点“?”表示，每小格为4次/分，相邻的脉搏以红直线相连。心率用红“?”表示，两次心率之间也用红直线相连。 ?脉搏与体温重叠时，先划体温符号，再用红色笔在体温符号外划 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 和田地区人民医院管理 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 编码:ZD/HL-A074 第 5 页 共 13 页 “?”。与肛温重叠时在蓝“?”内画红点“?”表示;与口温重叠时在蓝“?”外画红“?”表示。小儿4岁以上测脉搏。 ?脉搏短绌患者应同时测量心率和脉率，二者之间用红直线填满。 (3)呼吸 ?以阿拉伯数字表述每分钟呼吸次数，用蓝色水笔记录在呼吸栏目内。 ?如每日记录呼吸2次以上，在相应栏目内上下交错记录，每天的第1次呼吸记录在相应栏的下方。 ?使用呼吸机患者的呼吸以“R”表示，在体温单相应时间栏目内用蓝黑色笔顶格画“R”。 4.特殊项目栏包括:血压、入量、尿量、大便、引流量、体重、身高等需观察和记录的内容。 (1)血压 ?单位: 毫米汞柱(mmHg)。 ?记录方式:收缩压/舒张压(130/80)。 ?记录频次:新入院患者及时测量血压并记录，余根据患者病情及医嘱测量并记录 如为下肢血压需标注。栏目内每日可记录两次，若测量两次以上可记录在空格栏或护理记录单。新入院病人(包括7岁以上患儿)的首次血压常规记录在体温单相应栏内，以后每周测量一次，手术病人在上手术前应测量血压一次，并记录于体温单。术后按医嘱测血压。 (2)出入量 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe ?单位:毫升(ml)。可省略不写。 ?记录频次:将24小时总入量记录在相应日期栏内,每隔24小时填写1次。不足24小时按实际时间记录:量/时间(小时数) (3)尿量 ?单位:毫升(ml)或次/日。 ?记录频次:将24小时小便次数或总量记录在相应日期栏内, 填写在下午栏内，每隔24小时填写1次。不足24小时按实际时间记录:量/时间(小时数)。 ?“※”表示小便失禁，导尿以“C”表示，长期留置尿管以“C+”表示。长期留置尿管尿量记录:量/ C+ /时间(小时数)，如满24小时则不需写时间。 (4)大便 ? 单位:克(g)或次/日。 ? 记录频次:将24小时大便次数或总量记录在相应日期栏内,每隔24小时填写1次。填写在下午栏内。 ? 其他情况:患者无大便，以“0”表示; 灌肠后大便以“E”表示，分子记录大便次数，例:1/E表示灌肠后大便1次;0/E表示 灌肠后无排便; “※”表示大便失禁， “?”表示人工肛门。 (5)量栏(ml) 按医嘱或专科要求记录排出量，空格处填写排出液(引流、呕吐、痰等)的名称，将24小时量记录在相应日期栏内，不足24小时记录:量/ 时间。出入量记录，指前一日的出入总量，填写在当日的出入量tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 和田地区人民医院管理制度 编码:ZD/HL-A074 第 7 页 共 13 页 上午栏内。 (6)体重 ?单位:公斤(kg)。可省略不写。 ? 记录频次:新入院患者当日应当测量体重并记录，余根据患者病情及医嘱测量并记录。 ? 特殊情况:因病情重或特殊原因不能测量者，在体重栏内可填上“卧床”。“平车”，每周测量体重一次。 (7)身高 ? 单位:厘米(cm)。可省略不写。 ? 记录频次:新入院患者当日测量身高并记录，余患者根据医嘱或者专科要求测量并记录。小儿4岁以上测量身高。 (8)空格栏 可填写需要增加的观察内容和项目。使用HIS系统等医院，可在系统中建立可供选择项，在相应空格栏中予以体现。 三、 医嘱单记录要求 1.护士过长期医嘱应在医嘱单上签全名，执行临时医嘱后及时签上全名及时间。 2.医嘱有药物过敏试验者，应将药物过敏试验的结果填写在医嘱单上，阴性(—)阳性(+)。对于24小时后出现迟缓反应者，应及时记录在护理记录单上。凡出现药物过敏，有执行者将过敏药物的名称用红笔填写在一览表及床头卡的相应栏内，并及时告知病人。执行者在医嘱单上签名。 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 3.抢救结束后医生补记的口头医嘱执行护士应及时签全名和执行时间。 【填写说明】 (一)长期医嘱单 长期医嘱单内容包括患者姓名、科别、床号、住院病历号(或病案号)、开始日期和时间、长期医嘱内容、停止日期和时间、医师签名、护士签名、页码。其中，由医师填写开始日期和时间、长期医嘱内容、停止日期和时间。护士每天执行长期医嘱的给药单、输液单、治疗单等，由执行护士签名，不归入病历。长期医嘱单有效时间在24小时以上，至医生注明停止后医嘱方才失效。 (二) 临时医嘱单 临时医嘱单内容包括患者姓名、科别、床号、住院病历号(或病案号)、日期和临时医嘱内容、医师签名、执行护士签名、执行时间、页码。其中，由医师填写医嘱时间、临时医嘱内容;由执行临时医嘱的护士填写执行时间并签名。临时医嘱单有效时间在24小时内，应在短时间内执行，一般只执行一次。 四、危重护理记录单书写要求 1.使用蓝黑墨水书写，记录时间应具体到分钟。 2.危重护理记录由护士书写，实习生、进修护士所书写的危重记录，应当有本医疗机构执业护士修改和签名，带教老师签名/学生或进修护士签名。 3.适用范围:病重、病危患者，病情发生变化、需要监护的患者。 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 和田地区人民医院管理制度 编码:ZD/HL-A074 第 9 页 共 13 页 4.病重(病危)患者护理记录是指护士根据医嘱和病情对病重(病危)患者住院期间护理过程的客观记录。 5.病重(病危)患者护理记录内容包括:患者姓名、性别、年龄、科室、住院病历号(或病案号)、床位号、诊断、页码、记录日期和时间、根据专科特点需要病情观察、主要医嘱执行情况，监测的项目以及采取的治疗和护理 措施 《全国民用建筑工程设计技术措施》规划•建筑•景观全国民用建筑工程设计技术措施》规划•建筑•景观软件质量保证措施下载工地伤害及预防措施下载关于贯彻落实的具体措施 、效果评价，护士签名、页码等。护理记录应当根据相应专科的护理特点设计并书写，以简化、实用为原则。 6.按医嘱或专科要求及时观察病情变化、准确测量各项数值并记录。 7.每天9:00将24小时出、入量汇总于护理记录单上，不足24小时按实际时间书写、用红笔在时间和量对应的地方上、下划线标识。于末栏签全名，然后记录在体温单上。 8.抢救患者应在班内或抢救结束后6小时内据实补记抢救护理记录，内容包括病情变化、抢救时间及护理措施。 护理记录，内容包括病情变化、抢救时间及护理措施。只要使用危重护理记录单，必须记录24小时出入量，24小时总结一次，并同时将出入量总结结果转抄在体温单相应栏内。 9.监护记录，有监测医嘱的要详细记录所监护内容相关数据。 10.使用呼吸机病人应描述呼吸机呼吸模式及各 参数 转速和进给参数表a氧化沟运行参数高温蒸汽处理医疗废物pid参数自整定算法口腔医院集中消毒供应 。 11.病重(病危)患者出院、转入、转出科室应记录。 12.门急诊留观危重病人按危重护理记录要求书写。 (一)楣栏:包括患者科室、床号、姓名、年龄、性别、住院病历号、入院日期、诊断。 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe (二)项目内容 1.出、入量，单位为毫升(ml)。入量项目包括:使用静脉输注的各种药物、口服的各种食物(折算成含水量ml)和饮料以及经鼻胃管、肠管输注的营养液等。出量项目包括:尿、便、呕吐物、引流物等， 需要时，写明颜色、性状。按医嘱要求及时、准确、详细记录，注明出、入量的具体时间，每班小结一次，记录在病情观察栏内。出量下的空格栏可填写需要增加的观察项目和内容。 2.意识。根据患者实际意识状态选择填写、清醒、嗜睡、意识模糊、昏睡、浅昏迷、深昏迷、谵妄状态。 3.体温(T)，单位为?。直接在“体温”栏内填入测得数值，不需要填写数据单位。 4.脉搏(P)/心率(HR)，单位为次/分。直接在“脉搏/心率”栏内填入测得数值，不需要填写数据单位，脉搏短绌者同时记录脉率和心率。 5.呼吸(R)，单位为次/分。直接在“呼吸”栏内填入测得数值，不需要填写数据单位。 6.血压(BP)，单位为毫米汞柱(mmHg)。直接在“血压”栏内填入测得数值，不需要填写数据单位。 7.血氧饱和度，单位为%。根据实际填写数值，血氧饱和度，不需要填写数据单位。 8.吸氧，单位为升/分(L/min)。可根据实际情况、在相应栏内填入数值，不需要填写数据单位，并记录吸氧方式。 9.皮肤情况。根据患者皮肤出现的异常情况选择填写，如压疮、出血tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 和田地区人民医院管理制度 编码:ZD/HL-A074 第 11 页 共 13 页 点、破损、水 肿等。如有上述情况则要在病情观察栏内说明。 10.管路护理。根据患者置管情况填写，如静脉置管、导尿管、引流管等。 11.病情观察及措施。简要记录患者病情以及根据医嘱或者患者病情变化采取的措施 。 五、手术清点记录单填写要求 1.手术清点记录内容包括患者科别、姓名、性别、年龄、住院病历号(或病案号) 手术日期、手术名称、输血情况、术中所用各种器械和敷料数量的清点核对、手术器械护士和巡回护士签名等。 2.手术清点记录应当在手术结束后即时完成，由手术器械护士和巡回护士签全名 3.表格内的清点数必须用数字说明，不得用“?”表示。表格内的清点数目必须清晰，数字书写错误时应由当事人即时重新书写，不得采用刮、 涂等方法涂改。 4.空格处可以填写其他手术物品。 5.无菌包包外灭菌指示卡、植入体内医疗器具的相关标识、条形码粘贴于手术清点记录单背面指定处。 相关内容记录要求: 1.术前一日:预计手术时间，麻醉方式，手术名称，术前指导和部分术后指导。 2.手术:手术名称，麻醉方式、回病房的时间及情况，如生命体征变化、伤口敷料有无渗血、各引流管情况，镇痛药物使用情况及患者自tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 诉的感觉等。 3.体温:记录度数，发热时记录伴随症状，高热时降温的方法及效果。 4.脉搏:记录脉搏搏动的强、弱、节律、脉率。 5.呼吸:呼吸的性质、呼吸节律、呼吸的频率、伴随症状(或与活动的关系)。 6.意识状态:深/浅昏迷、谵妄、惊厥、嗜睡、昏睡、意识模糊、呼之能应、对答自如/能应、答所问。愉快、兴奋、平静、精神萎靡、烦躁不安。 7.瞳孔:大小、形状、对称性、对光反应。 8.面容表情:淡漠、痛苦、疲倦、忧虑、急性病容、慢性病容。 9.面色及皮肤:苍白、蜡黄、潮红、紫绀、有无黄染、灼热或湿冷。 10.皮肤黏膜:损伤性质、部位、面积、程度、伴随症状、处理、效果。 11.血运:颜色、温度、肿胀、弹性、毛细血管返流、感觉、活动。 12.活动体位:半卧位、平卧位、交替卧位和时间、活动方式、次数、时间、自由体位、被动体位、强迫体位(坐、蹲、仰、府、侧等)。 13.睡眠:入眠困难、原因、处理、(用药等)、效果。 14.饮食:食欲好坏、不振、饮食的种类、量。 15.排泄:时间、次数、性质、(形态、颜色)、数量、伴随症状。 16.自理:完全不能自理和部分不能自理者;具体描述不能自理的范围和程度(不能自行进食和洗漱、不能离床行走)。 17.咳嗽:性质、痰的颜色、量、黏稠度、气味、时间、频率。 18.出血:部位、数量、性质、来源、伴随症状、生命体征改变、病tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe 和田地区人民医院管理制度 编码:ZD/HL-A074 第 13 页 共 13 页 人情绪。 19.疼痛:时间、性质、部位、伴随症状、持续时间、处理、效果。 20.水肿:部位、范围、程度、进展、水泡。 21.抽搐:全身、局部、两侧、对称、偏于一侧，抽出时间、间隔时间、伴随症状。 22.护理处置:要求、时间、方法、处置前后情况描述，效果。 23.吸氧:用氧时间、吸氧方式、氧流量、用氧效果、必要时测量血氧饱和度。 24.灌肠:目的、灌肠液的名称、灌入量与排泄量、性质、时间、效果。 25.引流:名称(部位作用)、通畅、性质、量、部位、注意事项、伴随症状、处理、效果。 26给药:药物的给药时间、剂量、方法、注意事项、效果。 27.输液过程的监测与记录:特殊药物应记录滴数及调整依据。 28.抢救:病情变化时间、先兆症状、生命体征、告知、紧急处理人员、措施、效果。 tape per meter, and then slowly into the hole. (3) multiple point rod into hole, wireless sensor devices, and kongkouqiping, leads to the cable. (4) sealing grout guarantees hole filling full (back orifice pulp). Pulp opening hole after the final set 24h device, the detection of qualified, the cable leads, and then install the protective cover and protective covers. 10.5.9 water gauge (1) buried in the upstream dam surface of standard gauge, gauge should the measurement location and review on a regular basis. (2) draft survey measuring range should be above the maximum water level and below the minimum water level 0.5M. (3) 20~30cm the gauge width, minimum 0.1M, every 1M annotation elevation. 10.5.10 cable connection and protection (1) vulcanize rubber cable of the cable connector, plastic pyrocondensation joint of cable using hard links or sealant. (2) cable protection 1) cable connection, Epoxy painted or at the cable connectors into the wax to prevent moisture penetration. 2) should strictly prevent the corrosion oil stain cables, keep the cables clean and dry. 3) cable in traction during excavation blasting, construction to prevent mechanical damage to the cables, welding and welding residue burned out cables, pipe