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《Chinese Nursing Management》 2006-09
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Investigation and countermeasures on nursing duplicated records in grass-root hospitals

QU Jing, WANG Yan//the Nursing Depart- ment of Rongcheng People Hospital, Shandong Province, 264300 China  
Nursing record was a transcript of nursing process for inpatients according to medical order and patient’s condition. Some nursing record duplicated the record of medical record, medial order list, temperature list and blood pressure list. The duplication increased nurse’s workload, might not accord with facts, and might cause medical disputes. So, it is important to strengthen legal knowledge training to increase the risk consciousness of nurses working in grass-root hospitals, formulate writing standard which accord with ‘medical and nursing record standard’ and was convenient for clinical use, and train nurses to increase their writing ability.
【CateGory Index】: R47
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