二级医院ICU监护记录单的设计及应用

Design and Application of Comprehensive Mornitoring and Recording in ICU

总结了二级医院综合ICU患者监护记录单的设计及应用体会。监护记录单包括监测记录区、护理措施记录区、用药及出入水量记录区、基础护理记录区、管道护理记录区、病情变化及处理记录区、病情交班记录区、评估区等部分。该监护记录单能较全面、直观系统反映ICU患者病情变化,且使用方便、快捷,实时性、灵活性强,有效缩短了书写护理记录单的时间。

The article gives a summary of the second-grade hospital comprehensive patient care re- cords in ICU design and application experience. Monitoring record includes： monitoring and recording ar- ea, recording area, medication and nursing measures of access to water recording area, basic nursing re- cords, nursing records, pipeline area condition changes and treatment record area, condition shift re- cords, such as part of the assessment area. The writers think the custody records can be more comprehen- sive, intuitive, system reflect the ICU change of the patient＇ s condition, and the use is convenient, fast, real-time and has strong flexibility, and can effectively shorten the time of writing nursing records.