Basic Documentation in the surgical nurse and trauma departments

August 12, 2017 17:50 | Paramedic

nurse but perform clinical work and nursing, leading medical records.

1. Journal or book appointments.

2. Journal of the transmit and receive duty.

3. Leaf account of movement of patients and hospital bed hospital fund.

4. Portsionnik.

5. drugs Logbook list A and B.

6. A summary of the status of patients with the information desk.

7. Journal of Accounting extremely scarce and expensive drugs.

8. Journal dressings .

9. Journal of cheating materials and alcohol.

10. Magazine disinfection processing tools.

I. Journal predsterilizanionnoy processing tools.

12. Magazine general cleanings.

13. Magazine kvartsevaniya.

14. Log registration postinjection complications.In addition, it should be able to fill in the statistical card, (Form number 30).

15. tetanus emergency prevention magazine.

magazine or book appointments.Nurse prescribes medication as prescribed, and research that must be done to the patient, in a notebook assignments, which specifies the Namepatient room number, manipulation,

injection, laboratory and instrumental investigations.It duplicates the data record in the list of appointments.Be sure to put the date and signature of the nurse.

Journal of the transmit and receive duty.Most often, the transfer duty is performed in the morning, but can be done during the day, if one nurse working the morning, and the second - the second half of the day and night.Host and delivers the nurse on duty bypass the chamber, check the sanitary-hygienic regimen, visiting critically ill and painted in the Journal of the transmit and receive status, which reflects the total number of patients in the department, the number of seriously ill and febrile, moving patients, fixed-term appointments, the state of medical equipment, itemscare emergencies.The log must be clear, legible signature to accept and surrendered duty nurses.

nurse who give duty in the morning, fill the "Leaf accounting movement of patients" (form number 007u).

Ward Nurse, checking the list of appointments on a daily basis is "portsionnik" (if there is no of dietary sister).Portsionnik must contain information about the number of different types of dietary tables and unloading and individual diets.In patients admitted in the evening or at night, is portsionnik duty nurse.Information ward nurses on the number of diets adds senior nurse department, they are signed by the head of the department and then transferred to the catering department.

drugs Logbook list A and B. The drugs included in the list of A and B are stored separately in a special closet (safe).On the inner surface of the safe to be a list of such drugs.Narcotic drugs are usually stored in the same safe, but in a special compartment.The vault store is also in short supply and expensive means.Handing over the keys to the safe is recorded in a special register.To account for the consumption of drugs stored in the safe, the factory specialized journals.All sheets in these magazines should be numbered, bound, and the free ends of the cord to stick on the last page of the journal paper sheet, which indicates the number of pages.This sheet is stamped, as well as the head of the medical department signs.To account for the consumption of each drug from List A and List B allocate a separate sheet.Store the magazine also in the safe.Annual cost accounting of medicines is a senior nurse office.The nurse has the right to enter a narcotic analgesic is only after this appointment, the doctor records in history and in his presence.About to inject a note in the medical history and list of appointments.Empty vials are not thrown out of the narcotic analgesics, and is transmitted together with the unused ampoules nurse, proceed to the next shift.When the transfer duty check the appropriate entries in the log book (number of used vials, and the rest of) the actual number of used vials filled.When using the entire stock of narcotic analgesics empty vials shall be the senior nurse offices and instead issued new ones.Empty vials of the narcotic analgesics only be destroyed by a special commission, approved by the head of the medical department.

Logbook extremely scarce and expensive resources is drawn up and carried out in a similar way.

summary on the state of patients for the help desk.This summary is compiled daily night nurse, often early in the morning, before delivery change.It listed the names of patients, number of chambers, as well as their health.

The dressings log, the date, the types of dressings, the number of patients treated with ligation, and daily signature is placed.

Journal of cheating alcohol and the dressing is in the doctor's surgery or in the dressing room.This journal is numbered and laced, signed by the senior nurse and head of the department.Information nurse - alcohol consumption on the order №245 of August 30, 1991.

Surgical cabinet - 1200 g, 1 thousand people (1 person - 1.2 g of alcohol)..

Cancer study - 1000 g per 1 thousand people (1 person - 1 g of alcohol)..

Cabinet urologist - 1200 g per 1 thousand people (1 person - 1.2 g of alcohol).To apply a compress is required of 20-30 g of alcohol.burn treatment - 20-40 g of alcohol.

Similarly wool consumption is taken into account, bandages, furatsilina.Magazines disinfection tool handling, pre processing tools are compiled and maintained to monitor the relevant activities (see Table.).



disinfection log entry Example For instruments undergoing sterilization treatment in the CSO, the nurse must make a register of tools (see. Table.).


Example entries in the journal presterilizing cleaning tools

Journals general cleanings and kvartsevaniya drawn up and maintained to monitor the implementation of relevant procedures in the department (see Table.).


Example filling logbook tools

kvartsevaniya Mode - 8.00-8.30;13.00-13.30;17.00-17.30, after general cleaning kvartsevanie held for 2 hours. The title page should be an accession number, year of manufacture, putting into operation of the quartz lamp.After 3 thousand. Hours of quartz lamp happens to be replaced.


Journal kvartsevaniya

Surgical cabinet factory also log post-injection and post-surgical complications, which states the date, namepatient, home address, and who, when and under what circumstances made the injection, a drug was introduced, which was sent to the patient, whether to a medical certificate, issued name of the physician who examined the patient;After filling in all these Count nurse reported the case to the sanitary and epidemiological station, and the patient is assigned to an epidemiological number that registers a nurse in the same journal.

The trauma study, as well as in the surgical study conducted emergency prophylaxis of tetanus magazine, which specifies information about vaccinations, the quantity of the tetanus toxoid, its series and number, the amount administered tetanus toxoid, administration method, a series of serum and number as well as information onto whom transferred information about vaccinations.

Every nurse should be able to fill in statistical coupon for registration of further diagnosis (form № 025-27).In the upper left corner of the code is placed on the international classification of disease codes.

nurse must be able to fill in a sanatorium help and sanatorium card, the form number 30 (map of follow-up).When conducting documentation nurse handwriting must be legible, neat, prohibited corrections and erasures.