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《Chinese Medical Record》 2012-05
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Analysis and Preventive Countermeasures about Intensive Care Records Defects

Tian Shengnan,Li Na,No.Second Hospital of Hebei Medical University,Shijiazhuang 050000,Hebei Province,China,Ning Xiaohui,Hebei Provincial People's Hospital,Shijiazhuang 050000,Hebei Province,China,Kang Lixia,Hebei Provincial Traditional Chinese Medicine Hospital,Shijiazhuang 050000,Hebei Province,China  
Objectives this article researches defect of intensive care records and analyzes its legal risk,adapting preventive countermeasures and improving medical records quality.Methods It designs examination forms related regulations according to Nurse Regulations and Tort Liability Law.Intensive care records are randomly examined for summarizing defects,analyzing legal risk and reasons and discussing preventive countermeasures.Results There are 200 intensive care records are examined,in which 47 copies have error about number record;38 copies incorrectly implement doctor's advice;32 copies do not implement correct doctor's advice;14 copies do not implement informed obligation;19 copies incorrectly revise records;medical and nurse' records of 21 copies record are not unify.The severe records defects exists huge legal risk.Conclusions Intensive care record is vital evidence during medical tangle that should strengthen quality management of medical records and improve writing level of intensive care records.
【CateGory Index】: R47
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