Problems in nursing records and Countermeasures.doc

 PAGE \* MERGEFORMAT 7 Problems in nursing records and Countermeasures [Keywords:] nursing records, problems, improvements Care nurses in the medical records, nursing activities in the formation of words, symbols, diagrams, etc., collectively, is the implementation of nursing care and observation of patient illness in patients of the objective record, is an important part of the medical records. How to write to meet the requirements nursing documentation as nursing management and clinical nursing staff the important and difficult [1]. our hospital from January 2004 by the specialist nurses began writing under the care level of care records, other nurses writing at any time of the record. now select the 2005 and 2007 In the 500 hospitalized patients nursing records, care and control instruments, standards and specifications, as follows. 1 Problems in nursing records Inconsistent with the medical records of 1.1 lack of communication between medical staff, separate records, progress notes appear at the same time does not match the situation. Such as nurses recorded the patient conscious, bilateral sluggish pupillary light reflex, and physician records of confusion, bilateral pupillary light reflex disappear. part of the lack of knowledge of the nursing profession to observe the condition or conditions with subjective observations are not in place, not a very good collection of information, can result in inconsistent and physician records. 1.2 The relative shortage of nursing department nursing departments lack of patients with multiple, heavy workload, nurses busy with work, no time to observe the patient’s condition and medical records, there do not mind, do little in mind the phenomenon of mind after the meeting. 1.3 The lack of consistency in nursing records do not reflect the dynamic processes such as continuous high fever in patients with 17:00 to give physical cooling, the night shift, night shift nurses are not continuously detect the body