【Nurse Basics】Basic principles of how to write nursing records. Conferences, ICs, Muntera, Oral Instructions, Oyarihat (Incident), etc.
In the nursing records recorded by nurses in their daily nursing work, it is roughly decided what to write for each medical situation. In this article, I will explain mainly the basics of nursing records, such as conferences, ICs(informed consents), Muntera, oral instructions, oyarihat (incidents), etc., what kind of title should be written and what items should be written. I hope it will be helpful for new nurses and others.
Conference means conference, study group, council, study group, etc. However, roughly speaking in nursing, a talk is called a conference (or a camper for short).
The basic purpose of the conference is to improve the work content and improve the work environment.
While working as a nurse, there may be problems with the content of the nurse’s work. On the other hand, some inpatients may have problems. In addition, we will discuss at the conference whether the nursing plan planned at the time of hospitalization is appropriate and the evaluation of the nursing plan at the time of discharge.
A conference is a place where nurses discuss how to improve, take measures, and evaluate problems occurring in the business.
But it doesn’t mean anything in a conference that’s just a form or just an individual attack. There is no point in meetings where nurses cannot share information about problems and improvements. Therefore, it becomes important to keep it in the nursing record.
An example of a conference article is an example of how to write: It is a good idea to write the necessary information concisely in the form of a time recording.
Date: 0/0 10:00
Types of Nursing Records: Conferences
Content: Theme, current situation, problems, opinions discussed, future policy, direction, etc.
Informed Constant (IC), Muntera
Some of the most common medical terms are Informed Consent (IC) and Mundtherapie.
Both are meanings of explanation of medical conditions and examinations to patients, families, etc. In particular, when doing some kind of treatment, it is necessary not only to explain (inform) but also to agree (consent), so in such a case, ic is used.
ICs and munteras are mainly performed by doctors for patients and families. At that time, nurses should also be present to record the contents and responses of patients, families, etc. It is also very important to ensure that the content of the talk is recorded, as patients and family members may be asked for additional explanations and whether they have been told reliably.
As an example, here are some examples of how to write:
It is a good idea to write the doctor’s explanation and the patient’s reaction in chronological record format.
(Example of ic or Muntera report)
Date: 0/0 10:00
Type of nursing record: IC (or Muntera)
Contents: Doctor’s explanation, what was used, test data, treatment contents, questions such as patients and family members, responses, doctor’s answers, future policies, directions, etc.
* There are various ways to write depending on the ward and facility. Let’s describe it in a recording method tailored to each workplace, without being bound by the format.
Oral instructions from the doctor
In the medical field, nurses basically assist with medical care such as administration of drugs, wound treatment, and management of medical equipment under the direction of a doctor. Their contents can be described in the document, such as medical records, instruction books, and prescriptions.
However, sometimes it is urgent or for some reason it is not listed in the document. In that case, you may check directly with your doctor and get verbal instructions.
When receiving verbal instructions, it is important to check the details of which doctor, what, how much, and what to do, and repeat and confirm.
In addition to documents, especially with drugs, checking the name, quantity, unit, method of administration, etc. in detail will prevent accidents. Also, if you receive verbal instructions, be sure to keep a record of them. It is also important to ask your doctor to include the instructions in your medical account later. Be very careful when checking verbally.
As an example, here is how to write a nursing record of oral instructions.
It is a good idea to write down the details in the form of a time recording, such as the date and time, who, what, how, and how.
(Example of reporting oral instructions)
Date: 0/0 10:00
Type of nursing record: Oral instructions
Article: 00 Doctor verbally instructs me what, how, how, and what to do.
Oyarihat (incident) is a word that expresses a situation that was not likely to become an accident with “cold sweat = hyari” and “do not speak and take your breath away = hat”.
These include cases where wrong medical practices were about to be performed, but were able to be prevented by noticing beforehand, and cases where there was a mistake in the medical practice performed but there was no actual harm to the patient.
It is said that far more cases of oyarihats lurk behind the cases leading up to one accident (Heinrich’s law).
Therefore, it is said that collecting and analyzing cases of oyarihat, thinking about measures to prevent recurrence, and sharing the information will lead to the prevention of serious accidents. It was born in the field of occupational safety, and it can also be an incident for an accident = accident.
* Major failures and serious accidents are exactly the tip of the iceberg. There are many oyarihats lurking underneath!
I have seen many oyari hats in my five years of nurse work, and I have experienced them myself.
It’s important for Oyarihat not only to be limited to himself, but to share with everyone and reduce accidents for the entire team.
(Oyarihat report = incident report item example)
Date of discovery:
Date of birth:
Date of birth:
Where it occurs:
Oyarihat (Incident) Lister:
Years of experience:
Age of the patient:
Department of Medical Care:
Lessons learned and countermeasures:
Summary (In nursing records, it is important to always be aware of 5W1H)
When writing nursing records,
(1) Be careful not to record as only the parties do not know
(2) Take in “when, where, who, what, what, what happened”
(3) Have the recognition that information is shared
Note that. This is the basis for writing nursing records.
Write nursing records that can be read by third parties!
Thank you for reading so far.
In addition, I have written various articles such as experience of finding a nurse and changing jobs, salary (income), qualifications necessary for nurses, etc., so I would be happy if you could see it by all means!
Thank you in the future!
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