Simplify and attend to the document to get hold of degree

Simplify and attend to the document to get hold of degree
Simplify and attend to the document to get hold of degree
Staff reporter Sun Meng At the beginning of this year, Ministry of Public Health requires every medical organization to cancel unnecessary nursing to write, simplify and attend to the document, realize progressively that " returns time to a nurse and returns the nurse to the patient " ,Improve patient's satisfaction to care. At the beginning of March, new " case history writes the basic norm " attends to the document and writes the problem and becomes the focus that the insider pays close attention to again after implementing formally. Record and have too much " It is excessive to defend " Observing and lasting recording that be handled about condition of patient when if you can't hate, attend to on documenting. Chinese Medical Sciences University attaches to Wang AiPing, head of the nursing department of first hospital, and says, nurse's careful observation and recording effectively, can offer help for the making a diagnosis of the doctor to that patient's condition changes. To some teaching hospitals, still can offer the material for the fact that teaching making the rounds of the wards, teaching analysis is discussed with the case history to record to attend to. But nursing that carry out have some problems to record too on being at present clinical. Reporter hear of interview, have one nurse attend to one 7 day such as patient once, attend to, record, write 58,000 word right away only. The intersection of Jiangsu Province and department of public health cure the intersection of policy and the intersection of and the intersection of jasmine and duckweed Zhao, tell reporter, to add need that burden of proof invert while being nervous relationship between doctors and patients, cause various execution of doctor's order single, hand over, record singly, attend to the measure ' Stand up, press the sore, fall and assess etc.) Carry out and record and arise at the historic moment only. In fact, various data show, lead to the fact the case of the malpractice dispute is extremely rare because of attending to and recording, by attending to increasing clinically in a large amount the extremely low dispute to incidence of the document, " it is excessive to defend " It dislikes. Meanwhile, much nursing assess, attend to, record with the intersection of case and home in hospital, admitted to hospital, record generally and content that course of disease record repeat in a large amount, doctors and nurses are still often inconsistent when recording. Another kind of inclination is to attend to and record and become and attend to the basis of management, the nonsense, polite resulted in recording dawdle timidly for manpower, time too much. Many hospitals try to begin from the beginning of this year in table form of the document, the hospitals at all levels of the whole country have strengthened the pilot project of basic nursing successively, it is one of the pilot contents to simplify and attend to the document and write. It is told reporters that the affiliated hospital bone joint department's head nurse Huang Great Britain of medical college in Jining is beautiful, this institute has specially made the clinical route and attended to one in the course of managing the clinical route, attending to route design by form into,with before need now need to play only by hook just to content where nurse record a lot of. She says, Corey's nurse needs to specially spare about two hours and writing that attended to the case history every day in the past, all records are added up to only take half an hour is enough now. Zhao LiPing tells reporters, Jiangsu Province pursues the table form and attends to the document since 2008, specialized departments such as while making, woman, child, tumour,etc. consult forms and recommend use to second, tertiary hospital. At present, table form attend to document already in should save second, tertiary hospital, pursue in an all-round way, the coverage rate is up to 86%. She says, the nurse that should save now is average the time used for attending to and is written is only several minutes every day. Zhao LiPing says, attending to document tabulation brings the transition which attends to the management style too. Attending to administrator and health authority now already not only has consulted that attends to the record while checking the nursery work, but should go to look, should accord with the patient's feeling and demand while appraising. Three kinds of records can be simplified in practice, the nurses of a lot of hospitals are bitter to needn't immerse oneself in ing to write that welcome, but some questions that the administrators of some hospitals may bring after being in order to record and reduce worry about, will be too reasonable to make it clear after for example the medical dispute appeared, will influence and attend to discipline development,etc.. The new rule of Ministry of Public Health has been defined the nursing record which the nurse needed to write: The operation in body temperature form, doctor's order form, course of disease are recorded checks and records and attends to the record with the critically ill, seriously ill patient. Then, what contents are attended to and should subtracted on earth to record? Zhao LiPing thinks, the record which attends to the case history should be according to the needs of patient's condition, can't anything is written, can't understand mechanically that only just write when the doctor assign the critically ill, seriously ill doctor's order. Meanwhile, should complement one another with the doctor's record to record to attend to, stress that describes the physical sign of the life, coming in and going out amount, body posture, pipeline attending to, condition change and attend to the measure etc.. Zhao LiPing thinks, it can be simple that following these are attended to and recorded: First, general nursing of patient record, because condition change and treat, attend to measure can course of disease in doctor reflect record, during patient these in hospital; Second, the execution record of the doctor's order; Third, teaching, record that the quality accused of. She emphasizes, should control some to accuse of the means and nursing record form set up out of teaching purpose or quality strictly, including being attend to big case history, hand over, record singly, attend to the measure wholly ' Stand up, press the sore, fall and assess etc.) Carry out and record single and making an inspection tourly singly etc.. As far as reporter know, Ministry of Public Health has already trusted the association of Chinese hospital to make the table form and attend to the disease will and write the norm. The expert proposes, leave certain leeway while designing the form column, allow the hospital to supplement by oneself actually completely according to the clinical department.


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