Nursing records defects and interventions.doc

Nursing records defects and interventions [Abstract] In order to further improve my writing quality of nursing records. In this paper, in our hospital from January 2006 to June 2006 has been submitted to medical controls ‘medical records, Guangdong Province, written norms’ terminal quality control criteria and found that there are different degrees of impairment, and analysis of the causes of defects, made interventions measures. [Keywords:] nursing records; defects; interventions Nursing care records are kept by the patient’s condition to observe and implement the nursing care of the original written records, is the nursing staff in nursing activities reflected the real situation. With the people’s growing awareness of the law, people in the process of access to health care services, to safeguard their own interests more demanding, especially the new ‘Regulations on Handling Medical Accidents’ and other relevant laws and regulations of the promulgation and implementation of care records have been set out To address the legal basis of medical disputes. Therefore, the specification writing and management of medical records are conducive to enhancing the effect of the burden of proof to improve the quality of nursing records of the writing is the nurses to safeguard their own interests and achieve a solid foundation for self-protection. In this paper, in our hospital from January 2006 to June 2006 has been submitted to medical records for quality control terminal and found that there are different degrees of impairment, and analysis of the causes of defects and put forward interventions to further improve hospital care and medical records writing quality. A clinical data Samples in our hospital from January 2006 to June 2006 has been submitted to some 4180 copies of medical records and control ‘medical records, Guangdong Province, written norms’ terminal quality control criteria and found that 1531 copies of medical records there are different degrees o