การบันทึกทางการพยาบาล (Nursing Documentation)

การบันทึกทางการพยาบาล (Nursing Documentation)

(Nursing Documentation)Nursing Documentation) RN, PhD 1

5

1 - ( )

1

1 Maslow Gordon Orem Orem 1

2 2

2

3

4 (Nursing Documentation)narrative record)) (Nursing Documentation)Nursing process record)) (Nursing Documentation)Focus charting record)) (Nursing Documentation)problem oriented) record)) (Nursing Documentation)Computerized) Electronic Charting) (Nursing Documentation)Clinical pathway, Care map charting)

(Nursing Documentation)narrative record))

1..50 (08.0016.00.) 7.30. 10.30. o onoonnoonnoonnoon discharge nnoonn n noon T=37.2C, P=80/noon, R=18 /noonBP=120/80mmHg RN noo wetdressingpacko0.9%NSSnoonnoon

noonnnoonnnoonnonoon noonnoonn n oo noon T=37C, P =76/noon, R=18 /noonBP=120/80mmHg RN (Nursing Documentation)Nursing process record)) 3

. 1 2550 (08.00-16.00 .) 10.30.

- fowler - wet dressingpack0.9%NSS - - 4 - -

- - 10.00. T= RN 37.2C (Nursing Documentation)Focus charting record)) 3

oo(Nursing Documentation)DAR) DATA.

Action.. Response.. . 1 n 2550 (08.0016.00.) 10.30. o o

o - noon o - noon n m idline o o

n 1 - n fowler o o o o n - o o

pethidine 25 m g o r - noon n o { noon

- noon 4 noon - n o

noon o - noonnoon n noon n noon - n noon

n o o n n - noon 10.00. T=37.2C RN

(Nursing Documentation)problem oriented) record)) .. 1987 Lawrence Weed 4 (Nursing Documentation)problem oriented) record))

(Data base) Subjective data Objective data (Problem list) (Nursing Care Plan) (Progress note) 1 SOAP note SOAPIE note

S (Nursing Documentation)Subjective d)ata) O (Nursing Documentation)Objective d)ata) A (Nursing Documentation)Analysis) P (Nursing Documentation)Plan) SOAP SOAPIE I (Nursing Documentation)Interventions) E (Nursing Documentation)Evaluation) { 1 2

{ noonnon }no noon n noo o 4/1/53 4/1/53 6/1/53 . 1

2553 (08.0016.00.) 7.30. 12.00 . S: o noon n n n noon

o o O : - o n 1noon n m idline line n noon discharge - n n

noon noon - noon 88 /noon 100/60m m Hg A: noon : n

n P: n o n o n o I : -

o o noon n o noon j o o noon o - n fowler

o o o o n - o o pethidine25m g

o r - noon n { o noon E:- { o

noon n o noon o n o - n n

noon o RN RN

(Nursing Documentation)Computerized) Electronic Charting) = International Classification for Nursing Practice: ICNP

(Nursing Documentation)Clinical pathway, Care map charting) Case management

4 C Correct Complete Clear Concise

(Nursing Documentation)Correct) (Nursing Documentation)Correct)

(Nursing Documentation)Complete) 4

(Nursing Documentation)Clear) (Nursing Documentation)Concise)

(nurse s note)

(Nursing Documentation)Discharge Planning) McKeeHan (1981 , 2546)

Armitage (1995) Discharge planning

After care Referral Post hospitalization care (Continuing care Continuous care) /

(Assessment) (Plan) (Implementation)

(Evaluation) n { n } 1. nnnoon}o 1. }noonr 2. on o 2. on o no nnnoonnoon n 3. nnnonoonnn 3. noonnn

4. noo 4. on n 5. onoonnoon 5. } o onoon nn A professional-patient partnership model of discharge planning The partners-in-care model of collaborative practice Structured discharge procedure The A-B-C of Discharge Planning METHOD A professional-patient partnership mod)el of d)ischarge planning

Bull (2000) The partners-in-care mod)el of collaborative practice The partners-in-care model of collaborative practice (Nurse case manager)

Structured) d)ischarge proced)ure (structured discharge interview) Oral

steroids The A-B-C of Discharge Planning Step A: Assessment Step B: Build)ing a Plan Step C: Confirming the Plan

METHOD (2539) M-E-T-H-O-D Med)ication (Nursing Documentation)M) METHOD Environment and) Economic (Nursing Documentation)E)

Treatment (Nursing Documentation)T) METHOD Health (Nursing Documentation)H)

METHOD Outpatient Referral (Nursing Documentation)O) Outpatient Referral METHOD Diet (Nursing Documentation)D)

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