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《Chinese Medical Record》 2012-05
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Defect Analysis and Countermeasures in the Nursing Documents of 860 Medical Records

Qiu Yingqiong,Xu Qiaoting,Huizhou Hospital of Traditional Chinese Medicine,Huizhou 516000,Guangdong Province,China  
objective Through analysis on quality of nursing documents in our hospital,we need to strengthen legal consciousness of nurses and to improve writing quality of nursing records.Methods 860 copies of nursing document were selected randomly from medical records in 2010,including the nursing records,prescription sheets,as well as temperature forms,had examination analysis.Results There are 350 points of defects in all documents,in which 180 from the nursing records,90 from prescription sheets,and 80 from prescription sheets.Conclusion Nursing documents of hospitalization medical records are record during treatment and nursing,as well as legal basis for medical tangle.We need to pay attention to the writing quality of nursing document with strengthening legal consciousness of nurses and preventing medical tangle.
【CateGory Index】: R47
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【References】
Chinese Journal Full-text Database 1 Hits
1 Lu Yanzi,Chen Bei,Chen Fenqiong,Ma Xiangyan,Department of Medical Records,Shantou Longhu People’s Hospital,Shantou 515041,Guangdong province,China;Analysis of the Relationship between the Quality of Nursing Records and the Work State of Nurses[J];Chinese Medical Record;2013-04
【Citations】
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1 Yang Qin,Medical Record Department of Affiliated Hospital of Youjiang Medical College for Nationalities,Baise 533000,Guangxi Zhuang Autonomous Region,China;Analysis on Defects in Medical Record Writing[J];Chinese Medical Record;2010-09
【Co-citations】
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1 Liu Xin,Key Laboratory of Evidence Science (China University of Political Science and Law),Ministry of Education,100088;Shi Lei,Beijing Public Security Bureau,Beijing 100740.;Study of Evidence Preservation System in Medical Tangle Cases[J];Evidence Science;2009-03
2 CHENG Shouzhen, ZHANG Zhenlu, XIE Wen, ZHENG Shujun Author's address Nursing Department of the First Hospital Affiliated to Sun Yat - sen University, No. 58 the second Zhongshan Road, Guangzhou, 510080, PRC;Nursing Records in Favor of Quoting[J];Chinese Nursing Managemen;2003-05
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4 Zhen Jinxiang(Coal Central Hospital of Shanxi Province,Shanxi 030006 China);Checking and analysis of writing quality of nursing documents and its strategies[J];Chinese General Nursing;2008-36
5 ;护理行为导致护理纠纷的原因分析及对策[J];Journal of Clinical Nursing;2006-05
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Chinese Journal Full-text Database 1 Hits
1 HUANG Pin,WANG Yi-fang,LU Yan-zi,LIN Pei-jian,LIN Xue-zhen 1 Long Hu People's Hospital of Shantou,Shantou,515041,Guangdong 2 The Second Long Hu People's Hospital of Shantou,515041,Shantou,Guangdong;An Investigation and Analysis on Work Engagement Status of Nurses[J];Today Nurse;2012-09
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