What are the eight major nursing books?

The eight major nursing books include: superior physician’s ward round record, difficult disease discussion record, critical and critical rescue record, death case discussion record, medical quality control record, consultation record, and business learning Record book, error and accident record book.

1. Superior physician’s ward round record book: It is required to record the ward round time, ward, bed number, patient’s name, gender, age, hospitalization condition, diagnosis, name and professional title of the ward rounder, focusing on recording the superior physician Provide guidance to subordinate physicians.

2. Difficult disease discussion record book: To discuss difficult cases with unclear diagnosis or poor treatment effect, it is required to record the time, location, participants, and moderator (the academic leader of the department, attending physician or above) Professional title), the medical history reported by the treating physician, the opinions of physicians at all levels, focusing on recording the exact opinions on diagnosis and treatment, the host's summary, and recording of the physician's signature, etc.

3. Emergency and critical rescue record book: It is required to record the rescue time (specific minutes), location, names and professional titles of all personnel participating in the rescue; patient name, gender, age, hospitalization number, and diagnosis. Record in detail the occurrence, development, and evolution of the disease, the detailed process and measures of rescue, and the result of rescue (success or failure), with the full name of the recorder.

4. Death case discussion record book: For inpatients who died due to ineffective treatment, the discussion must be completed within one week of death (the autopsy will be discussed before the autopsy), and the time, location, and participation of the discussion must be recorded. Personnel, moderator (discipline leader, attending physician or above or medical department organization), medical history reported by the treating physician, name, gender, age, occupation, hospitalization number, time of death, death diagnosis (including diagnosis of traditional Chinese medicine and Western medicine) , record in detail the diagnosis and treatment process, the deterioration of the condition, the rescue process and the main measures, record the analysis of the cause of death and the lessons to be learned, the host summarizes, and the recorder signs the full name.

5. Medical quality control record book: This book accounts for 50% of the quality control score of the general department. It reflects the level of medical technology quality within the department. It is based on the requirements of the hospital's hierarchical management for each department. Analyze the problems existing in the writing of internal medical records, find out the reasons, propose next rectification measures, conduct statistical analysis on various rates, find out the reasons for unfulfilled indicators, and propose solutions and rectification measures, which can be done monthly and quarterly. , half-year and year-end analysis.

6. Consultation record book: including incoming and outgoing consultations, focusing on recording incoming consultations, recording time, patient name, gender, age, hospitalization number, and planned physician from a certain department or hospital. name and professional title, and then record the consultation conclusion in detail. For the consultation sent out, record the time of dispatch, a certain department or hospital, and the name and professional title of the doctor.

7. Business learning record book: record the lectures held in the hospital or department, record the time, location, speaker, participants and content. It can also record the talent training plan, measures and implementation status of the department. In the record book.

8. Error accident record book: It is required to record the time, place, object, cause, responsible person, handling situation, lessons learned and future countermeasures of the error accident.