Basic documentation in the work of the nurse of the surgical and traumatology departments
Apr 22, 2018
A nurse, in addition to doing medical work and nursing, conducts medical records.
1. Journal, or notebook assignments.
2. Journal of reception and transfer of duty.
3. The list of records of the movement of patients and hospital bed fund.
5. Journal of the registration of drugs of the list A and B.
6. Summary of the status of patients in the reference table.
7. Journal of Accounting for Expensive and Acute Deficiency Drugs.
8. Journal of dressings .
9. Magazine on the copying of materials and alcohol.
10. Journal of disinfection of tools.
I. Journal of pre-sterilization processing of tools.
12. Journal of general cleaning.
13. Journal of quartz.
14. Post-injection complications log. In addition, she must be able to fill in the statistical coupon,( form No. 30).
15. Journal of emergency tetanus prophylaxis.
Journal or notebook of assignments. The nurse prescribes prescribed medications, as well as studies that must be performed by the patient, in the prescription booklet, where the name of the patient is indicated.patient, room number, manipulation, injection, laboratory and instrumental research. It duplicates the entries in the assignment list. Necessarily put dates and the signature of the nurse.
Journal of Reception and Transmission of Duty. Most often, the transfer of duty is made in the morning, but can be made in the afternoon, if one nurse works the first half of the day, and the second - the second half of the day and at night. The nurses on and off duty bypass the wards, check the sanitary and hygienic regime, inspect the seriously ill and register in the reception and transfer of the duty register, which reflects the total number of patients in the ward, the number of seriously ill and febrile patients, the movement of patients, urgent appointments, medical equipment, itemscare, emergency incidents. In the journal, there must be clear, legible signatures of nurses who have accepted and handed over the watch.
A nurse who goes on duty in the morning, fills out the "List of records of the movement of patients",( form No. 007y).
The ward medical nurse checks the appointment list every day, making a "portioning"( if there is no diet sister).Portionnik should contain information on the number of different dietary tables and types of unloading and individual diets. On sick, arrived in the evening or at night, the porn-player is the duty nurse on duty. Information of the ward nurses on the number of diets is summarized by the senior nurse of the department, they are signed by the head of the department, then transferred to the food box.
A list of drugs of list A and B. Medicines included in lists A and B are stored separately in a special cabinet( safe).On the inside of the safe there must be a list of these medicines. Narcotic drugs are usually stored in the same safe, but in a special compartment. In the safe are also highly scarce and expensive means. The transfer of keys from the safe is registered in a special magazine. To account for the consumption of medicines stored in the safe, special magazines are set up. All the sheets in these magazines should be numbered, stringed, and the loose ends of the cord glued on the last sheet of the magazine with a paper sheet, which indicates the number of pages. This sheet is stamped, and the head of the treatment unit is signed. To account for the expenditure of each drug from list A and list B, a separate sheet is selected. Store this magazine, too, in the safe. The annual accounting of the expenditure of medicines is maintained by the senior nurse of the department. The nurse has the right to introduce a narcotic analgesic only after recording this appointment by the doctor in the medical history and in his presence. About the made injection the mark in a case history and in the sheet of appointments is made. Empty ampoules from narcotic analgesics are not thrown out, but they are handed over together with the unused ampoules to the nurse, who is about to start on the next duty. When transferring the watch, the records in the register of records( the number of ampules used and the remainder) are checked to the actual number of filled ampoules filled. When using the entire stock of narcotic analgesics, empty ampoules are handed over to the senior nurse of the department and new ones are given in return. Empty ampoules from narcotic analgesics are destroyed only by a special commission approved by the head of the treatment unit.
The register of highly scarce and expensive funds is compiled and maintained according to a similar scheme.
Summary of the patients for the reference table. This summary is compiled daily by the night nurse, most often in the early morning, before the change is given. It lists the names of patients, the numbers of their wards, and the state of their health.
The journal of dressings indicates the date, types of dressings, the number of patients who received dressings, and a daily signature is put.
The magazine on the copying of alcohol and dressing material is in the surgical room or in the dressing room. This journal is numbered and tied, signed by the senior nurse and the head of the department. For the information of the nurse - the consumption of alcohol by order number 245 from August 30, 1991.
Surgical room - 1200 g per 1 thousand people( 1 person - 1.2 g of alcohol).
Oncological office - 1000 g per thousand people( 1 person - 1 g of alcohol).
Cabinet of the urologist - 1200 g per 1 thousand people( 1 person - 1.2 g of alcohol).Compressing requires 20-30 g of alcohol. Burn treatment - 20-40 g of alcohol.
The consumption of cotton wool, bandages, furacilin is also taken into account. Logs of disinfection processing tools, pre-sterilization processing tools are compiled and maintained to monitor the relevant activities( Table).
Example of entry in the disinfection log
For instruments that undergo sterilization treatment in the CSO, the nurse must create a logbook of the instrumentation( see table).
Example of a log in the pre-sterilization cleaning of
instruments. The general cleaning and quartz materials logs are compiled and maintained to monitor the implementation of the corresponding procedures in the department( table).
Example of filling the accounting log of toolkit
Quartz mode - 8.00-8.30;13.00-13.30;17.00-17.30, after the general cleaning, the quartz is carried out for 2 hours. The title page should have an inventory number, the year of production, the commissioning of a quartz lamp. After 3 thousand hours of operation of the quartz lamp, it is replaced.
In the surgical room there is also a log of postinjection and post-surgical complications registration, where the date is indicated.patient, home address, as well as who, when and under what circumstances he injected, which medication was administered, where the patient was sent, whether he was given a sick leave sheet, the name of the doctor who examined the patient;after filling in all these graphs, the nurse reports this case to the Sanitary and Epidemiological Station, and this patient is assigned an epidemiological number that the nurse registers in the same journal.
In the traumatology room, as well as in the surgical room, a journal of emergency tetanus prophylaxis is carried out, where information about vaccinations is given, the amount of tetanus toxoid injected, its series and number, the amount of antitetanus serum administered, the method of administration, serum series and number, and information about that, to whom information about vaccinations is transmitted.
Each nurse must be able to fill out a statistical ticket for registration of specified diagnoses( form No. 025-27).In the upper left corner is a cipher of the disease according to the international classification of ciphers.
A nurse should be able to fill out a sanatorium certificate and a sanatorium card, form No. 30( dispensary observation card).When maintaining the documentation, the nurse's handwriting should be legible, neat, and corrections and erasures are prohibited.