Hypertension nursing medical record writing

Traceable, verifiable, and implementable - there is no need to write a running account to make up for the word count, nor to use rigid templates to fill in irrelevant content. All records must correspond to the patient's individualized status and the actual closed loop of nursing actions.

Speaking of how to write clinical records for hypertension care, there are actually two different ideas. One group is the "minimalist" group. They believe that clinical nurses are responsible for more than a dozen beds alone and are already too busy to touch the floor. There is no need to write nonsense. They only need to record abnormal blood pressure values, corresponding intervention measures, and post-intervention effects. There is no need to write down routine blood pressure monitoring three times a day and general education as long as there are no abnormalities. The time saved by going to the ward twice more is better than anything else. The other school is the "full record school", especially in departments with a high risk of doctor-patient disputes. They feel that even if a patient casually asks "Why is my blood pressure 5mmHg higher today?", it must be written down. Otherwise, if the patient later says, "You never reminded me about blood pressure fluctuations," there will be no supporting records and no way to report the loss. There is actually nothing wrong with both of these statements. The key depends on what kind of patient you are managing: if you are an old patient who has had high blood pressure for ten years and has particularly good compliance, and your blood pressure is as stable as a Dinghaishen needle, a minimalist record is completely sufficient. ； If you encounter someone whose blood pressure fluctuates greatly, has a lot of family matters, and doesn't follow the doctor's advice, writing two more strokes can really save a lot of trouble.

I went through a similar trap when I was first transferred to the cardiovascular department. At that time, I managed a young and middle-aged patient in his 40s who was obese and loved to drink milk tea. When he was admitted to the hospital, his blood pressure was 168/102mmHg. I followed the template and wrote "Educate on low-salt and low-fat diet." However, on the third day, he secretly ordered a cup of full-sugar pearl milk tea, and after drinking it, his blood pressure went straight to 180/110mmHg. His family asked me in turn, "Why didn't you say you can't drink sweet things?" ”I was stupid when I looked through the medical record - I only wrote low-salt and low-fat, and it did not increase sugar and affect blood pressure. In the end, I could only preach again in a good tone, and made up the record when I got back. Don't underestimate these details. Many times, disputes are just half a sentence short of the record.

The 62-year-old Uncle Zhang who I managed before is a very typical example. He is an alcoholic, his children work outside, and he only has his wife with a bad memory to accompany him in bed. The first time I taught about the risks of drinking, I specifically wrote, "Educate the patient and accompanying family members on the impact of drinking on blood pressure at 16:10. The family members said they would supervise the patient to reduce his drinking, and the patient himself said he would try to gradually quit drinking in the near future." As a result, three days later, he secretly drank half a glass of liquor sent back by his son. In the afternoon, his blood pressure reached 172/101mmHg, and he had a slight head bloating. I gave him nifedipine to relieve it. After the tablets were released, the retest dropped to 145/89mmHg. In addition to recording the values and intervention process, a special sentence was added: "Re-emphasis on the risks of drinking, and the patient promises not to drink on his own in the future." After that, his wife asked us if we could eat before bringing him food, and he never secretly drank again. Later, when the shift was handed over, the nurse who took over after reading the records knew that he should pay more attention to his eating problems, which saved a lot of communication costs.

Oh, by the way, when recording, do not write subjective judgments, such as "the patient's blood pressure is well controlled" or "the patient's compliance is poor". You must write "The blood pressure of the brachial artery of the right upper limb was remeasured at 14:30, which was 132/84mmHg, which was higher than the previous time (10:0 0, 156/92mmHg) dropped, and there was no complaint of dizziness, headache or discomfort.” “The patient reported that he did not take the antihypertensive medication this morning as directed by the doctor, again emphasizing the importance of regular medication.” All content must be concrete, without personal emotions or vague descriptions. If the patient has underlying diseases such as hemiplegia and vasculitis that affect blood pressure measurement, the limb to be measured must be clearly marked every time the measurement is taken, for example, "The mobility of the left upper limb is impaired, and the blood pressure of the brachial artery of the right upper limb was measured to be 142/86mmHg." Otherwise, other nurses will not know next time and will measure the affected side and get a significantly different value, thinking that the blood pressure has suddenly fluctuated, so they should do more checks.

When I write, I have a little habit of reading the records of the first two shifts before writing. If I see that the patient’s blood pressure is above 150/90mmHg at 8am for three consecutive days, even if his blood pressure is normal now, I will add "The blood pressure at 8am for the past three days has been above 150/90mmHg." The blood pressure fluctuates between 152~168/90~98mmHg, and the doctor in charge has been informed that the time to take antihypertensive drugs tomorrow will be adjusted to 7 o'clock in the morning." Don't think this is meddling. Many times, the doctor's basis for adjusting medicines comes from these inconspicuous continuous records.

To be honest, the hypertension care medical record is essentially a "patient instruction manual" left for colleagues who take over later. You don't have to worry about whether to go for a minimalist or a full record, and you don't have to cram in the number of words to write it like a paper. What you write can let the next person who takes over the job know at a glance where the patient's risk points are, what he has done before, and what to pay attention to next. It is considered qualified.