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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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