Defects in orthopedic nursing records and Countermeasures.docVIP

 PAGE \* MERGEFORMAT 11 Defects in orthopedic nursing records and Countermeasures [Abstract] checks orthopedic hospital care hospital medical records of 876 copies, 256 were found to have substandard care and records, problems are: lack of authenticity of records, lack of accuracy and completeness of records, records related to the lack of security knowledge of mission, records lack of continuity of functional training, record a lack of consistency. the main reasons are: the legal consciousness, lack of rigorous scientific approach records, the low level of business, professional knowledge is not solid, the lack of communication between health care and so on. views: focus on training nurses, legal awareness, improve nursing their own quality and service level, strengthen health care communication, standardize nursing records and writes standards, strengthen the quality of nursing records management measures, and effectively improve the quality of writing nursing records, medical records to reduce defects caused by medical malpractice. [Keywords:] orthopedics, nursing records, defect analysis, strategy Clinical nurses involved in nursing records in writing a number of potential legal issues, especially the “burden of proof” and the new lt;lt;Medical Malpractice Billgt;gt; [1] The introduction of the writing of nursing records a higher demand In order to improve the quality of medical records and reduce medical defects caused by medical malpractice, by summarizing our hospital, orthopedic hospital medical records 876 copies, 256 copies of unqualified nursing records relating to analysis of the problems and propose preventive measures, are presented as follows. 1 Clinical data Heshan City People’s Hospital extraction of Orthopaedic Surgery, January 2007-December 2008 876 were discharged from medical care and records to the Office of Health Care Quality Control Centre, Guangxi Zhuang Autonomous Region on the lt;lt;Care Records in the basic specificat