in our department from the hospital in 2013 were col ected 310 cases were analyzed, and the related quality control personnel to the nursing records was evaluated, the existing defect classification, summary, analysis. Results: there are many defects in nursing records, such as nursing records appear blank, nursing record writing is not standard, the language is not smooth, the body temperature single lacunary, doctor's advice related defects and treatment of daily life and other related records do not match. In view of the above situation, our hospital has increased efforts to control the quality of nursing records, and formulated a series of nursing quality control personnel regulations, to strengthen the quality control of medical records, for the defect rate to a minimum. By adopting the above measures, the nursing records to achieve true, accurate, objective requirements, so as to improve the quality of nursing records and patient's living standards, and achieved good results.
NETL
NSTL
万方数据
