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Make patient medical records for nursing clinics.

Let's make patient medical records.# Clinic # Kiri Maz # Medical records # Kyrimaz Nursing Clinic # Nursing clinic

2025/10/7 Edited to

จากที่เราเริ่ม “ทำเวชระเบียนผู้ป่วย” ในคลินิกพยาบาลเอง สิ่งที่เจอบ่อยมากคือคนไข้ถามเรื่อง “สำเนาเวชระเบียน” ว่าขอได้ไหม ขออย่างไร และต้องมีอะไรบ้าง เลยอยากมาแชร์แนวทางแบบใช้งานจริงในคลินิกให้ค่ะ (ทําเวชระเบียนกันจ้า) สำเนาเวชระเบียน คือเอกสาร/ชุดข้อมูลที่คัดลอก “ข้อมูลการรักษา” ของผู้ป่วยออกมาให้ผู้ป่วยหรือผู้มีสิทธิ์ ใช้ไปประกอบการรักษาต่อ ทำประกัน ส่งต่อสถานพยาบาล หรือใช้ยืนยันข้อมูลทางการแพทย์ ทั้งนี้รายละเอียดที่ออกสำเนาได้ขึ้นอยู่กับวัตถุประสงค์และนโยบายของแต่ละแห่ง สิ่งที่เราแนะนำให้เตรียมไว้ในระบบคลินิก (เพื่อทำสำเนาเวชระเบียนได้ง่าย) 1) แบบฟอร์มเวชระเบียนมาตรฐาน 1 ชุด: ข้อมูลทั่วไป, อาการสำคัญ, ประวัติแพ้ยา/โรคประจำตัว, สัญญาณชีพ, การประเมิน, แผนการพยาบาล/การรักษา, ยาและคำแนะนำ, นัดหมาย 2) เลขที่เวชระเบียน (HN) และวันที่รับบริการชัดเจน: เวลาออกสำเนาจะค้นหาเร็วมาก 3) เอกสารแนบ: ใบยินยอม, ใบส่งต่อ, ใบนัด, ใบรับรอง (ถ้ามี) ขั้นตอนที่เราใช้เวลามีคนไข้ขอ “สำเนาเวชระเบียน” - ให้ผู้ขอยื่นคำร้องขอสำเนา ระบุช่วงวันที่ต้องการ และเหตุผล (เช่น ส่งต่อ/ประกัน) - ตรวจสอบตัวตน: บัตรประชาชนตัวจริง หรือกรณีผู้รับมอบอำนาจให้มีหนังสือมอบอำนาจและสำเนาบัตรทั้งสองฝ่าย - เลือกขอบเขตข้อมูล: บางเคสต้องการเฉพาะสรุปการรักษา/รายการยา ไม่จำเป็นต้องทั้งแฟ้ม จะช่วยลดข้อมูลส่วนเกิน - ทำสำเนาและรับรองเอกสารตามนโยบายคลินิก: เซ็นรับรอง/ประทับตรา (ถ้ามี) พร้อมระบุจำนวนหน้า - บันทึกการออกเอกสารลงทะเบียน: เพื่อความปลอดภัยและตรวจสอบย้อนหลังได้ ทริคเล็กๆ ที่ช่วยให้เวชระเบียน “ทำสำเนาได้ไว” - เขียนให้ครบทุกครั้งโดยเฉพาะวัน-เวลา, ผู้ให้บริการ, รายการยา/หัตถการ - ใช้คำย่อเท่าที่จำเป็น และทำให้ทีมใช้รูปแบบเดียวกัน - จัดแฟ้มตามปี/เดือน หรือแยกตาม HN แล้วติดสันแฟ้มชัดๆ - ถ้าเป็นไฟล์ดิจิทัล ให้ตั้งชื่อไฟล์มาตรฐาน เช่น HN_ชื่อ_วันที่ สุดท้าย อย่าลืมว่าเวชระเบียนเป็นข้อมูลส่วนบุคคลและข้อมูลสุขภาพ ควรเก็บให้ปลอดภัย จำกัดผู้เข้าถึง และให้สำเนาเฉพาะผู้มีสิทธิ์เท่านั้นค่ะ ถ้าใครทำคลินิกพยาบาลเหมือนกัน อยากได้ตัวอย่างแบบฟอร์มหรือวิธีจัดแฟ้มที่ใช้จริง บอกได้เลย เดี๋ยวเรามาแชร์เพิ่มเติมค่ะ

A handwritten list titled "Human Body" detailing numerical facts like 206 bones, 639 muscles, 2 kidneys, 14 bones in the face, 22 in the skull, 25 in the chest, 6 in arms, 2 heart pumps, 33 bones in the foot, 8 in the wrist, 27 in the hand, 24 ribs, 20 milk teeth, 4 heart chambers, and 33 vertebrae in the spine.

A handwritten list titled "Facts About Human Body" showing normal ranges for medical parameters: blood pressure (120/80), pulse (70-100), temperature (37°C), breathing (12-16), cholesterol (130-200), potassium (3.5-5), sodium (136-145), blood amount (5-6 Ltr), sugar (70-115), iron, WBC, RBC, platelets, calcium, and hemoglobin levels.

A handwritten list titled "Facts of Human Body" outlining general facts such as skin being the largest organ, liver the largest internal organ, 600-840 muscles, femur as the longest bone, stapes as the smallest, 206 total bones, kidneys as filters, heart as the pump, 33 vertebrae, normal body temperature (37°C), body pH (7.3-7.4), 230 joints, common and least common blood types, brain mass (1400gm), and heart mass for men (340gm) and women (250gm).

Need-to-Know Medical Facts ✨

Whether you’re in nursing, radiology, sonography, or any healthcare path, these are core facts every medical mind should have locked in. From blood pressure ranges to the number of bones in the human body, these basics are the foundation for understanding patients and providing quality care. 📌 W

7051 likes

A tablet displays nursing notes on a Head-to-Toe Assessment, surrounded by medical-themed stickers like a blood pressure cuff and lungs. The text "Steal my notes" is prominently overlaid.

Detailed handwritten notes for a Head-to-Toe Assessment, covering introduction, normal vital signs (HR, BP, SpO2, T, RR), patient orientation, and head and face examination steps, including PERRLA and cranial nerve assessment.

A tablet shows Head-to-Toe Assessment notes, with the overlay text "Follow more content and follow for Part 2." The tablet rests on a desk next to a notebook.

Head-to-Toe Assessment for Nursing School

Important things to know when doing a Head-to-Toe Assessment. You will be doing this a lot in nursing school and after school during your regular work shift so be sure to know these things!!! . . . . . #nursingstudenttips #nursingschooltips #nursing #study #stealmynotes

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Nursing student cheat sheet

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Nursing Fundamentals

Got lots to share! These are older notes from my first ever nursing exam! Blessed to say that I have one exam left of my first semester. Wish me luck! We all have it in us! #fundamentalsofnursing #nursing #nursingstudent #nursingschool #lemon8diarychallenge

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A person in black scrubs holds a phone, with blue text overlays reading "NURSING CHEAT SHEETS MEDICAL SURGICAL" and a right arrow symbol. The background shows a colorful abstract painting and a window.

A white page titled "B - Medical-Surgical Terms" lists 10 medical conditions, including Bradycardia, Burns, Bronchitis, and Bowel Obstruction. Each entry provides a definition, PNLE clue, and nursing notes.

A white page titled "C - Medical-Surgical Terms" lists 10 medical conditions, including Cholecystitis, COPD, Cirrhosis, and Cushing's Syndrome. Each entry provides a definition, PNLE clue, and nursing notes.

Medical surgical cheat sheets ✨🍋✨

#nursingstudent #nursing #nursingstudentlife #nursingnotes #nursing

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Nursing Careers Outside Hospitals🩺💉✨

Hey Girlies🩺 Are you interested in becoming a nurse but are not necessarily excited about working in a hospital setting? This is for you ✨ School Nurse. 🏫📚 • Provide basic healthcare for students, handle minor injuries, administer medications, and educate on health issues. They also manage

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An iPad displays "FIVE HIGH PAYING Non-Nursing Careers" with a stethoscope and a Coach bag, indicating career opportunities in healthcare that require a degree in two years.

A radiation therapy machine and control panel highlight the Radiation Therapist role, detailing a salary range of $72-120K for administering radiation treatments to cancer patients.

Dental tools and a person in pink scrubs holding a mirror illustrate the Dental Hygienist profession, with an earning potential of $85,000+ for providing preventive oral care.

5 High-Paying Non-Nursing Healthcare Careers!

Looking to make a great salary in healthcare without becoming a nurse? 🌟 Check out these 5 high-paying professions that offer rewarding careers and excellent earning potential! Whether you're interested in technology, diagnostics, or patient care, there's a path for you. 💼💰 #HealthcareCare

9138 likes

A person in blue scrubs stands in an elevator, with text overlaying the image that reads: 'Nursing exam strategies my clinical instructors taught me.'

A study desk with notes, a laptop, and a drink. Text highlights keywords like 'FIRST,' 'PRIORITY,' 'BEST,' and 'IMMEDIATE' to guide answering nursing exam questions.

A study desk with notebooks and a laptop. Text emphasizes the 'Safety first rule' for nursing exams, advising to choose answers that protect the patient, prevent harm, and reduce complications.

Nursing study tips 🫶🥰✨

#nursingstudenttips #nursestudents #nursingstudent #medicalstudent #nursingstudenthelp

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Non-Nursing Medical Jobs🩺💉✨

Hey There✨ I’ve noticed that a lot of people are very interested in the healthcare field and not necessarily in becoming nurses and doctors, so I threw a list of some healthcare careers you can look into🤍🩺 🛠️1. Biomedical Equipment Technician (BMET) Role: BMETs are responsible for installin

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The image displays the first part of 'Fundamentals of Nursing - 100 Flashcards', covering questions 1-12. Topics include the nursing process (ADPIE), nursing diagnosis, short-term and long-term goals, and ethical principles like autonomy, beneficence, nonmaleficence, justice, fidelity, and accountability.

This image shows questions 13-26 from the nursing flashcards. It covers HIPAA, informed consent, advance directives, the nurse's role as an advocate, evidence-based practice, scope of practice, delegation, standard precautions, infection prevention, transmission-based precautions, glove use, and PPE.

The image presents questions 27-40 of the nursing flashcards. Topics include PPE removal order, patient positioning for breathing, normal adult vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation), signs of hypoxia, medication administration rights, patient identification, aseptic technique, SBAR, and ADLs.

Nursing fundamental Flash Cards

Hope this helps❤️

328 likes

A person in blue scrubs with a blood pressure cuff and stethoscope on a table, next to a worksheet for vital signs practice. The image is captioned "Future Nurses: Save This!"

A nursing study guide detailing airborne, contact, and droplet isolation precautions. It lists indications and considerations for each, including private rooms, negative pressure, N95 masks, surgical masks, and cohorting patients.

A nursing study guide explaining common acronyms for drug delivery routes. It lists abbreviations like PO, SC, IM, IV, and their corresponding routes and descriptions, such as oral, subcutaneous, intramuscular, and intravenous.

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Fundamentals of nursing

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Medical terminology you need to know🖤

Whether you’re a med student, a nursing major, or just someone who’s passionate about healthcare these must-know medical terms will level up your clinical vocabulary. 💉📚 I made two simple tables with 15 terms each, including definitions, so you can review fast without overwhelming info. These ar

978 likes

A laptop displaying a medical diagram is surrounded by handwritten nursing notes and cheat sheets on a wooden desk, with "Nursing diagnosis Cheat sheets" overlaid.

A close-up of a handwritten nursing cheat sheet titled "related to (R/T): as EVIDENCE BY (AEB)," listing various nursing diagnoses like "Activity intolerance," "Acute anxiety," and "Grief" in two columns.

A close-up of a handwritten nursing cheat sheet, continuing the list of diagnoses from the previous image, including "Dehydration," "Fluid overload," "Pressure injury risk," and "Vomiting."

Nursing diagnosis’

Nursing diagnosis’ to help you make perfect care plans #patientcare #nurse #nursing #nursingstudent #nursingschool #careplan #hospital #medicine #medicalstudent #patientcaretechnician

529 likes

This image is a nursing study guide on cardiovascular topics, including preload, afterload, hypertension, cardiomyopathy, acute chest pain, and STEMI treatment protocols. It details definitions, symptoms, and interventions for these conditions.

This image is a nursing study guide on respiratory disorders, covering pneumonia, COPD, pleural effusion, ARDS, and asthma. It outlines pathophysiology, signs/symptoms, nursing management, and patient education for each condition.

This image is a nursing study guide on Tuberculosis, defining the disease, its spread, signs/symptoms, diagnostic tests (skin test, sputum, X-ray), first-line medications, and essential nursing interventions like isolation and education.

Nursing notes that helped me 🙂

Make sure to save these!!

252 likes

A nursing dosage calculation cheat sheet with conversions (e.g., mg to mcg, kg to lbs, oz to ml), abbreviations, rounding rules, dimensional analysis steps, and examples for solid and oral liquid medications.

An NCLEX cheat sheet listing normal ranges for vital signs, common lab values (electrolytes, BUN, creatinine, blood counts), arterial blood gases (ABG), glucose, BNP, and cardiac output.

A medication math cheat sheet detailing formulas for weight-based, injection, tablet, IV drug, and liquid calculations, along with key conversions, abbreviations, rounding guidelines, and safety reminders.

Nursing School Cheat sheet

#patientcaretechnician #medicaltesting #nursingschool #patientcare #summerbod

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Jobs in Healthcare🩺✨ Other than Nursing

Hey Girlies✨ Here are some healthcare non-nursing jobs that might be of your interest🩺🩷 Unit Clerk: Education: High school diploma or equivalent; some positions may require a certificate in medical terminology or healthcare administration. Salary: $30,000 - $45,000 annually, depending on ex

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A laptop displaying "Medical Assistant" text, an open notebook with handwritten notes, pens, and a water bottle on a desk, suggesting a study session.

A YouTube channel page for "Medical Assisting with Ms. K" with 57.1K subscribers, featuring a video thumbnail of Ms. K in scrubs.

A YouTube playlist titled "NHA CCMA Rapid Review" by Smarter MA, showing video thumbnails with a man and text about certification test questions.

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Hey girl heyyyy.. 💕 Now we all know studying can get boring😴 or it feels like you’re not retaining the information that you’re getting. Here’s my top list of resources to use. And let me tell you Ms.K is my absolute favorite 🤩 ! She’s breaks everything down to layman’s terms but also keeps it me

1265 likes

10 Different Nursing Jobs🩺✨

Hey Girlies🎀✨ I wanted to share with you 10 different nursing branches, including their roles and average pay🩺 1. Registered Nurse (RN) Role: Provides direct patient care, administers medications, performs assessments, and educates patients. RNs work in various settings, including hospitals

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QUICK MNEMONICS FOR NURSING STUDENTS

#mnemonics #nursing #nursingstudent #nursingschool #nursingstudenttips

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FUNDAMENTALS OF NURSING NOTES

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HEALTHCARE Jobs for YOU🩺✨

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A flat lay of various pink and white nursing school supplies, including a backpack, laptop, stethoscope, books, planners, and stationery, arranged on a bed.

Close-up of pink medical supplies including a stethoscope in a case, medical scissors, penlights, and a pulse oximeter, laid on a surface.

Pink over-ear headphones next to a pink daily prayer journal and a beige gratitude journal on a light-colored surface.

Nursing School supplies 🤍💕

As an adult, going back to school has been very fun getting my supplies in the color I want. I remember growing up and not being able to do that sometimes, my mom did her best and I love her for it 🤍. I am so thankful for all the support! Some of my stuff is not in yet or off getting embroidery 🥹

1280 likes

Handwritten medical assisting notes on a lined notebook page, detailing the digestive system, including definitions of digestion, alimentary canal, food movements, and a list of digestive organs from mouth to large intestine, with key terms highlighted.

Medical Assisting notes! 🌟📝

Steal my notes from the first week of my clinical medical assisting class! The parts I had to remember the most or found to be the most helpful in remembering the topic are highlighted although not everything is. Hope this helps someone! #notes #study #medicalassistant #school #paper

161 likes

Cosmetic Nursing ✨🩺

#aestheticnurse #nurseesthetician #nursesoftiktok #nurse #creatorsearchinsights

540 likes

A person stands in front of a mirror, holding a phone. Overlay text reads "Part time Jobs For Nursing Students Swipe to learn impact and pay," introducing the topic of part-time jobs for nursing students.

A waiting room scene with a potted plant and framed signs. Overlay text identifies the role as "Appointment Coordinator" with an "Avg Salary: $17-20 per hour."

A laboratory setting with various bottles, a mortar and pestle, and papers on a counter. Overlay text identifies the role as "Pharmacy Technician" with an "Avg Salary: $18-22 per hour."

PART TIME NURSING SCHOOL JOBS AND PAY 💰🧑‍⚕️

Thinking about a part-time job while in nursing school? Roles like Appointment Coordinator, Pharmacy Tech, and Phlebotomist offer amazing hands-on experience for nursing students! The pay information may vary from state to state. Here’s how each role makes a difference: 🔹 Appointment Coordinator

283 likes

A screen displays "NURSING SCHOOL NOTES Part 1" in pink text, with background text mentioning the pituitary gland, HGH, milk production, and parathyroid hormones. A "Next" button is visible, along with a Lemon8 watermark.

A page titled "All about Nclex" lists 62 hallmark signs and symptoms for various medical conditions, such as pneumonia (rusty sputum), asthma (wheezing), MI (crushing pain), and meningitis (Kernig's sign).

This page continues the Nclex notes, listing additional symptoms (63-66) and sections on Immunology, Allergies, Immunizations, Leadership, and Delegation, including rules for RN, LPN/LVN, and UAP assignments.

NURSING SCHOOL NOTES

Hey nursing girlies 💗 Here are some notes I found online! Lmk if they help! #nursingstudent #nursingnotes #nclexprep #nursingstudenttips #nursingstudentaesthetics

320 likes

The image features the title "Healthcare careers that DON'T require a degree" in bold pink text, set against a background of various healthcare-related icons like thermometers, syringes, and first aid kits. A pink arrow points right at the bottom.

This image details the Patient Care Technician (CPCT/CPCA) role, including duties, training, pay ($15-$23/hour), program length (4-12 months), work environments, certification options, and requirements like a high school diploma and CPR/BLS.

This image describes the Medical Assistant (CMA/CCMA/CMAA) role, covering clinical and administrative tasks, training, pay ($17-$26/hour), program length (4-12 months), work settings, certification options, and growth tips for career advancement.

🌟 entry level healthcare jobs 🏥

5 healthcare careers/jobs that don’t require a 2-4 year degree and are great for entry level positions! They also serve as great stepping stones into nursing or other healthcare professions or degrees! (Check other post on my page for a little more information on these) #medicalassistant #pat

6308 likes

Nursing students

#GrowWithLemon8 #nursingstudent #nursingschool #nursing #medicalschool

156 likes

A handwritten, colorful guide detailing a head-to-toe nursing assessment, covering general history, integument, head, eyes, ears, nose, mouth, throat, lungs, cardiovascular, abdomen, GU, neurological, and musculoskeletal systems, with assessment techniques.

A checklist-style form for a head-to-toe assessment, including sections for level of consciousness, orientation, mentation, communication, vitals, pain, hair, eyes, nose, and ears, with checkboxes and spaces for notes.

A vertical infographic outlining a head-to-toe assessment, with sections like General, Eyes & ENT, Neurological, Integumentary, Respiratory, Gastrointestinal, Genitourinary, and Musculatory, each accompanied by a relevant icon.

Head to Toe Nursing Assessment

Always do your head-to-toe assessments in the same order. You will learn quickly that, just walking into your patients' room, looking at them, and talking to them will check off a good portion of the assessment. #nursingassessment #nursingschool #nursingschoolstudytips #youcandot

440 likes

✨ Medical Made Simple ✨

The medical field can feel like a whole new language, but breaking it down into easy terms makes it less intimidating. Whether you’re studying, working in healthcare, or just curious, knowing these basics can really help. 🩺 The first chart covers common medical abbreviations and their full forms

615 likes

NHA Certifications 🎓

The National Healthcareer Association (NHA) offers 8 certifications to apply for! 8 certifications offered: 🩺 Medical Assistant (CCMA) 💊 Pharmacy Technician (CPhT) 🩸 Phlebotomy Technician (CPT) 📞 Medical Administrative Assistant(CMAA) 🫀 EKG Technician (CET) ⌨️ Electronic Health Records

1166 likes

A table titled 'Medical Terminology' lists 67 common medical prefixes, their meanings, and example words. It includes prefixes like 'hypo-' (low), 'hyper-' (high), 'brady-' (slow), and 'tachy-' (fast), which are crucial for understanding medical terms.

A table titled 'Medical Terminology' lists various medical suffixes from '-ac' to '-metry', along with their meanings and example words. This section helps in understanding the latter part of medical terms, such as '-itis' (inflammation) and '-ectomy' (removal).

A table titled 'Medical Terminology' continues the list of medical suffixes from '-oid' to '-us', providing their meanings and example words. This comprehensive list aids in deciphering complex medical vocabulary by breaking down terms into their component parts.

Why Medical Terminology Matters!

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3453 likes

A nursing cheat sheet titled 'Symptoms of Hypothyroidism' using the mnemonic 'M-O-M IS T-I-R-E-D' to list symptoms like memory loss, obesity, impaired fertility, slowness, skin dryness, tiredness, intolerance to cold, raised BP, and depression.

A nursing cheat sheet titled 'ACID-BASE MNEMONIC' using 'R-O-M-E' to explain respiratory (opposite pH/PCO2) and metabolic (equal pH/HCO3) acid-base imbalances, indicating alkalosis and acidosis.

A nursing cheat sheet titled 'Pharmacology' listing common drug class suffixes and their corresponding drug types, such as '-amil' for calcium channel blockers, '-caine' for local anesthetics, '-dine' for anti-ulcer agents, and '-olol' for beta blockers.

NURSING CHEAT SHEETS✨

#lemon8diarychallenge Hey friends it’s Faye, I’m obsessed with this app. I seen these cute little study cards for Nursing Students and just wanted to share because girls who share are girls who care 🥹💕🥹 Faye Out 🥰 #nursingstudenttips #nursestudent #patientcaretechnician #m

252 likes

A tablet displays handwritten notes on "Fundamentals of Nursing: HIPAA Edition," outlining key points about the Health Insurance Portability & Accountability Act. Decorative stickers like a medical shield, "STUDY TIME," and a clock are overlaid on the screen.

This image defines HIPAA as the Health Insurance Portability & Accountability Act, emphasizing its role in protecting client privacy. It highlights that HIPAA rules are critical for nurses and are heavily tested on exams, detailing the first key point about sharing client information on a need-to-know basis only.

This image continues the HIPAA key points, advising against discussing client information in public areas, accessing unneeded charts, or sharing computer passwords. It also covers logging off computers, proper disposal of report sheets, and rules regarding client information releases.

Fundamental of Nursing-HIPAA edition

The fundamentals of nursing is one of the first subjects you will study in nursing school. Here are a few key points to know about HIPAA. . . . . . #nursing #nurse #nursingstudent #studywithme #phlebotomy

323 likes

Fundamentals Of Nursing

Hey Baddies 🥰 , Hope Everyone Had A Great Weekend . Here Are Chapters 1-7 . Especially as Requested By @itssleahaa 🥰 make sure to follow and comment as i keep sharing more of my personal notes and practice questions 🥰 #nurse #nursingschool #nursingstudenttips #nursingstudent #nursingjour

622 likes

How to survive nursing school 101

Imagine paying thousand of dollars to go to nursing school just to realize your teachers are not the one that you learn anything from. Teachers will reiterate to you over and over again that they are there to just do overview and it’s your job to make sure you learn the material. it’s extremely dis

180 likes

A handwritten comparison chart detailing Type 1 and Type 2 Diabetes, covering aspects like cause, age of onset, risk factors, symptoms, prevention, and treatment. It outlines differences in insulin production, development, and management strategies for each type.

$A handwritten study guide illustrating and describing various types of bone fractures, including Greenstick, Spiral, Oblique, Transverse, and Comminuted. It also outlines the three stages of bone healing: Hematoma formation, Cellular proliferation, Callus formation, Ossification, and Consolidation and remodeling.$