Nursing observation records a dispute hidden Analysis and Intervention Strategies.doc

 PAGE \* MERGEFORMAT 9 Nursing observation records a dispute hidden Analysis and Intervention Strategies [Keywords:] nursing records; disputes hidden; Intervention Strategies Analysis and Prevention of the Hidden Medical Dispute in Nurse Records Keywords:: Nurse records; Hidden medical dispute; Prevention Care nurses observed and recorded under the doctor’s orders and patient care during hospitalization for patients disease process, an objective record of clinical work is a first-hand information, or proof of both nurses and patients based on [1]. According to September 1, 2002 shall come into force by the Ministry of Health, the State Drug Administration issued the ‘Regulations on Handling Medical Accidents’, ‘basic norms of medical writing (for Trial Implementation)’ (hereinafter referred to as specifications) regulatory requirements, in writing nursing records injected into the legal awareness, improve the quality of nursing records is now the new problems facing the nursing work. Now available through the extensive collection of information, analysis disputes existed in nursing records analyzed risks to explore the intervention measures and methods. 1 General information and methods In our hospital from May 2003 began to implement the above ‘standard’ requirements, writing nursing records. Select from October 2005 to March 2006 Nursing Writing quality control checks, there is nursing records dispute the medical records of 200 hidden dangers to carry out analysis of intervention measures and methods. 2 Results 200 copies of medical records hidden in the distribution of care: nursing records in time 76, the condition does not match with the actual record of nine copies, nursing care does not match with the actual six copies of the content of an empty non-specific 95 copies, six copies of medical records are inconsistent, out time and the doctor’s advice Nurses implementation of the time is not consistent with eight copies. 3 Nursing