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《Chinese Medical Record》 2012-01
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Common Defects and Improvement Countermeasures of Nursing Medical Records

Huang Zhaoyan,Yang Feng,Liang Jiangping,Quality Management Office,No.476 Clinical Department of Fuzhou General Hospital of Nanjing Military Region,Fuzhou 350028,Fujian Province,China  
Objectives to improve quality of nursing medical records.Methods 1000 nursing medical records are examined in order to analyze the reasons of defects and to adopt improvement countermeasures.Results The common defects are incomplete items filling,nursing records without conforming to medical records with copy and etc;the reasons of that are insufficient value,faint legal consciousness,insufficient quality control.The improvement countermeasures are to strengthen on-the-job nursing training,quality segment control in medical records writing and legal concept and to improve nurses' legal and quality consciousness.Conclusions It applies effect countermeasures to settle defects of medical records well,improving writing quality of nursing document for preventing the occurrence of medical nursing tangle.
【CateGory Index】: R47
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