NURSING CLINICAL RECORDS (Nursing Sheet), - Coggle Diagram
NURSING CLINICAL RECORDS (Nursing Sheet)
Record all data related to the patient in a real, complete, concise, legible and timely manner.
Provide continuity of care provided by the nursing professional.
What is it?
It is the written evidence of the signs, symptoms and the care given to the patient. They are a means of communication and coordination between health professionals.
It must contain at least:
Vital Signs Chart
Procedures carried out, observations and changes.
Fall risk level
Pressure ulcer prevention indicator
Full name and signature of the nurse who made the note
Observations regarding health status
Therapeutic measures applied
Patient behavior and responses
Official Mexican Standard NOM-004-SSA3-2012 From the clinical record.
Drafting the nursing sheet
It must be: Objective, accurate, concise, complete and consistent.
It should be prepared by the nursing professional on duty, according to the frequency established by the internal regulations of the institution, using the color of the ink corresponding to the shift..
Do not use pencil, do not cross out, do not leave blank spaces, no abbreviations.