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‫الداخلى‬ ‫القسم‬ ‫في‬ ‫المعلومات‬ ‫توثيق‬ ‫قائمة‬ WARD/UNIT: ………………………. DATE: ……………………… CRITERIA : 1. Does admission notes contain the following data: 1-‫الدخول‬ ‫ملحظات‬   1. 1. Mode of admission ‫الدخول‬ ‫نوع‬ 1. 2. Patient s condition on admission... More

‫الداخلى‬ ‫القسم‬ ‫في‬ ‫المعلومات‬ ‫توثيق‬ ‫قائمة‬ WARD/UNIT: ………………………. DATE: ……………………… CRITERIA : 1. Does admission notes contain the following data: 1-‫الدخول‬ ‫ملحظات‬   1. 1. Mode of admission ‫الدخول‬ ‫نوع‬ 1. 2. Patient s condition on admission ‫عند‬ ‫المريض‬ ‫حالة‬ ‫الدخول‬ 1. 3. Patient s vital signs on admission ‫عند‬ ‫الحيوية‬ ‫العلمات‬ ‫الدخول‬ 1. 4. Complete nursing assessment of the patient (from head to toes) ‫التمريضي‬ ‫التقييم‬ 1. 5. Date and time indicated ‫والوقت‬ ‫التاريخ‬ 1. 6. AV fistula, prosthesis if any. 1. 7. Legibility of handwriting ‫الملحظات‬ ‫قراءة‬ ‫سهولة‬ 1. 8. Patient attended by which doctor ‫المعالج‬ ‫الطبيب‬ ‫اسم‬ 1. 9. Are doctor s orders completely carried out and noted ‫الوامر‬ ‫تنفيذ‬ 1. 10. Disposition of valuables ‫الممتلكات‬ ‫حفظ‬ 1. 11. Signature of nurse and the PN or CRN number ‫الممرضة‬ ‫توقيع‬ 1. 12. Any IVF, site and date indicated ‫المحلول‬ ‫تركيب‬ ‫تاريخ‬ 2. Daily notes should report: 2-‫يومية‬ ‫ملحظات‬ 2. 1. Change Less