The design and management of nursing case records for patients with acute cerebrovascular disease / 中国实用护理杂志

ABSTRACT

Objective To discuss the design and content management of the nursing case records for patients with acute cerebrovascular disease.Methods We modified the former nursing case records(NCR)by adopting the "filling in the blank" recording style and reducing time cost for repeated writing.The new NCR demonstrated the time characteristic of vital signs changes and neurological signs changes such as consciousness,pupil and paralyzed muscle strength.It could also superintend the record of admission,hospitalization and discharging of patients.Results It met a standardized nursing record management after the modification and showed the specialized nursing services with simplified and integral characteristics.The new NCI fitted legal requirement,pretected the rights of nurses and favored for the quality control and management of nursing cases.Conclusion The newly modified NCI contributes to the nursing quality for hospitalized patients with acute cerebrovascular disease.