9.16 : 护理记录的格式

Nursing documentation employs various formats to ensure precise and comprehensive patient records, optimizing accuracy and ease of understanding.

Firstly, a nursing assessment form captures precise patient data from physical assessments and nursing histories.

Secondly, a Kardex is a nursing record filing system that offers a concise patient summary.

The card's exterior displays the patient's diagnosis, activity levels, diet, vital signs, diagnostic investigations, medications, and treatments.

The interior contains a nursing care plan that outlines nursing diagnoses, desired outcomes, interventions, and safety precautions.

Next, the nursing care plan is a roadmap for nurses and patients to collaborate in achieving goals. It includes nursing assessment, diagnosis, plan, intervention, and desired outcome.

Critical pathways are interdisciplinary care plans that outline patient problems, necessary interventions, and expected outcomes within specific timeframes.

Similarly, progress notes inform caregivers about a patient's progress toward expected results. Focus charting is an example.

Lastly, flow sheets document patient conditions and trends, such as vital signs monitored over time.