Nursing documentation of medical problems and related legal responsibilities.doc

 PAGE \* MERGEFORMAT 8 Nursing documentation of medical problems and related legal responsibilities Study: Cheng Lu Wang Qiaoping Xujie An as Paper Keywords: nursing records and legal issues Countermeasures Nursing a nurse on the medical documentation of changes in patient’s condition, treatment, nursing care situation and the measures taken by the whole record, is the clinical work of the original written records, the doctor observed clinical results to adjust one of the important basis for treatment, but also handling medical disputes legal documents. With the lt;lt;Medical Malpractice Billgt;gt; implemented, health care environment has undergone major changes in content and form of nursing records is facing many new problems, how to improve nursing care quality writing that will record more timely , accurate, complete, now combined with medical documents written in our hospital care problems, put forward its own with the law. 1 question at this stage in the nursing records. 1.1 The Ministry of Health and altering phenomenon prominent State Administration of Traditional set lt;lt;basic norms of medical records (Trial)gt;gt; hereinafter referred to as lt;lt;Specificationsgt;gt; provided for non-altered or forged medical records Vi. In writing nursing records, due care trivial and busy work, prone to typos or other characters, resulting in signs of nursing records altered quite common, there are many individual records altered, or even alter the entire line, thus affecting the authenticity of records. 1.2 nursing records are not timely, incomplete or omission, wrong in mind, make note phenomenon in critically ill patients and patients with diagnostic uncertainty, lack of individual nurses careful observation of the disease, failed to identify problems and make a record, but to be condition deteriorated further memories of description, which led to a record and the actual person. If there is work in the nursing care records are not tim