Diabetes care record sheet writing content

Basic patient information, dynamic blood glucose monitoring data, medication and intervention records, diet and exercise implementation, observation results of complications and adverse reactions, health education and follow-up arrangements, all records must follow the principle of "true and traceable, specific and reusable, and can directly guide subsequent diagnosis and treatment", and cannot be vaguely stated, let alone fictitious content.

Last month, I went to the community health service center near my home to help sort out the chronic disease files. I happened to meet Nurse Zhang, who is in charge of diabetes, reviewing with a young nurse. She said that last week, a 72-year-old diabetic patient suddenly had a blood sugar of 13mmol/L. The previous nursing records did not include any special circumstances. After asking for a long time, I found out that the old man's great-grandson came the day before and ate half a piece of cream cake. The nurse who wrote the record at the time thought "there is no need to write down such a trivial matter." Instead, the doctor spent half an hour checking whether there was any drug resistance problem.

Talking about the specific writing details, the writing methods of different institutions are actually quite different, and there is no absolutely unified standard. For example, in the hospitalization record form of the endocrinology department of a tertiary hospital, the header usually contains only the most important information: name, age, type of diabetes, years of diagnosis, baseline blood sugar range, and drug allergy history. The rest are placed in the large medical record to avoid overly cluttered headers and time-consuming search for key information. ； But when it comes to community health service centers, many nurses will take the initiative to add the patient's compliance status, whether he has family members to accompany him, and whether he drinks or smokes regularly. After all, the community cares for the elderly, and many people cannot remember their medical history. Writing a few more sentences can save a lot of effort in follow-up communication. The industry does not say which of these two methods is absolutely correct, as long as the core information can be conveyed in place.

Don’t be too troublesome with blood sugar data. It’s useless to just write down a numerical value. You have to write down the conditions clearly. For example, “fasting fingertip blood 7.2mmol/L, the patient reported that he got up 3 times last night and did not eat midnight snacks” is much more useful than a single “7.2mmol/L”. If you encounter In the case of hypoglycemia, it is necessary to write down the status before and after: "At 15:20, the patient complained of palpitation, cold sweats, and fingertip blood 3.5mmol/L. He was given 2 soda crackers as directed by the doctor. The blood sugar was retested at 15:35 and was 4.7mmol/L. The discomfort symptoms were completely relieved." Oh, yes, there is also a little controversy: Should the outpatient follow-up record sheet include all the patient's self-tested blood glucose values ​​in the past half month? Some doctors think it is enough to just write "the fasting average is 6.8, the postprandial average is 9.2, and the maximum is 11.3" to save time. ； Some doctors insist on writing down the time corresponding to the abnormal value and whether there are any special circumstances, so as to facilitate finding fluctuation patterns. Now many electronic records will directly synchronize the patient's blood glucose meter data, which can be considered as taking into account both needs.

There must be no mistakes in medication and intervention, especially if the dose is temporarily adjusted, it must be written clearly. For example, if you usually take 8 units of insulin aspart, but today your fasting blood sugar is high, and the doctor temporarily asked you to increase it to 10 units, you must write down the reason for the adjustment, the adjusted dose, and the injection site, as well as the leakage of oral medication. Dosage status and adverse reactions after taking the medication, such as "Slight diarrhea occurred after taking metformin. The patient has been told to take it with food and observe for 3 days to see if it is relieved." I have encountered some nurses before who thought that adverse reactions were trivial and did not need to be written down. As a result, the next time the patient had diarrhea, he thought it was because he had eaten something bad, which was a big detour.

When recording diet and exercise, it is most taboo to write vague clichés such as "diet is in compliance" and "exercise is up to standard". It is really useless. Just write the specific content that you have confirmed with your own eyes or that the patient clearly stated: "Today's staple food is about 2 taels of multi-grain rice, 10g of plain nuts after lunch, no high-glycemic foods, brisk walking for 30 minutes after dinner, no dizziness and chest tightness." There was an aunt who had high blood sugar on Wednesdays for three consecutive weeks. After looking through the records, I found out that she had to pick up her grandson from school every Wednesday. Her grandson loved to eat cones, and she would take two bites of them every time. If she hadn't memorized the details of her diet every time, she wouldn't have been able to find the reason for such a hidden fluctuation.

The observation of complications does not need to be too complicated. Just focus on the high-risk problems of people with diabetes, such as numbness in hands and feet, blurred vision, and skin damage that is not easy to heal. Especially the observation of the feet. Many elderly people with diabetes have insensitive peripheral nerves and may break their feet automatically. I didn't feel anything at all. I took a look at each follow-up visit and wrote down any problems immediately: "Both feet are not damaged, and the pulse of the dorsalis pedis artery is normal. The patient complained of occasional numbness in the fingertips of his right foot in the past week. He has been told to observe carefully and seek medical advice promptly if the frequency of numbness increases."

The last step is health education and follow-up arrangements. Don't just write "education has been done." Write clearly what has been taught and how well the patient has mastered it: "This time, the patient has been taught how to rotate insulin injection sites. The patient can now complete the injection operation independently. He is told to avoid soaking his feet in water exceeding 40°C. A follow-up appointment is scheduled for next Wednesday morning, and he is reminded to bring a home self-test blood glucose record book."

To be honest, writing a nursing note is really not just to cope with the examination. Every sentence you write may help the doctor avoid a lot of detours when the patient comes back for treatment next time. Don't bother with it, and don't follow a template. Just write what you saw with your own eyes, what the patient said, and what you actually did. It will work better than anything else.