How to write nursing medical records? With the implementation of the "Regulations on Handling Medical Accidents", the quality of writing medical records has received more and more attention from hospitals. Nursing medical records are an integral part of the entire medical record and are as important as medical medical records. Correct writing has a guiding role in improving the efficiency of nursing work and the quality of nursing care. 1. Correct writing of nursing records. The nursing record sheet (critically ill patients should have a critical care record sheet) should be written in strict accordance with the template content, with the medical orders as the subject of the record, and at the same time reflect the routine nursing contents of each specialty, and understand the meaning and requirements of the medical orders one by one. And it should be consistent with the doctor's orders. The recording content should be objective, specific, true, timely and dynamically connected. Do not write subjective inferences, conclusions or general language casually. The recording method should be recorded in three paragraphs, that is, problem - treatment - effect. , and there are no taboo words to describe it. First-level care should be recorded at least once a day, secondary care should be recorded at least once every 3 days, and tertiary care should be recorded at least once every 7 days. Emergency admissions should be recorded continuously for 2 days. When the condition changes, it should be recorded in time. The order is emergency first, then routine, first current condition then other conditions, first special then general. The content on the medical order should be complete, standardized, timely and implemented without omissions. The drawing of the temperature sheet should be true, correct, complete and standardized, with dots, circles and straight lines. 2. The current problems in nursing records are that the nursing records are not detailed, such as: tracheotomy, no record of sputum suction and description of sputum; the special care record sheet only writes about taking medicines on time, but no record of changes in the condition; after removing the urinary catheter, there is no record of the change of the condition; Tube record and whether the patient can relieve himself or herself to urinate. Writing errors and word mismatches, such as: calm mind; urinating 4 times a day, 60 mL; intravenous infusion; drowsiness; many gender and age inconsistencies in the same medical record. Do not use medical terminology, such as: drink two sips of water; do not use medications indiscriminately, do not over-fatigue, and do not rely on hearsay. The nursing record is inconsistent with the doctor's course of illness and medical orders. For example: the doctor's course of illness has a positive record of penicillin, but the nursing record does not; the doctor records that both eyes are insensitive to light, and the special care record shows no light reflex; the doctor's order is absolute bed rest, but the nursing record shows bed rest. Activities in bed; doctor's order is fasting, nursing record is loss of appetite. The nursing records are inconsistent and inaccurate, such as: the recording time is inconsistent with the specific content time; on October 28, it was recorded that there was a lot of intraoperative bleeding, and on November 12, the discharge summary recorded that the operation was smooth and there was not much bleeding. There is a lack of introduction of disease knowledge to family members. 3 Quality management 3.1 Strengthen the professional training of nursing staff. Strengthen the training of young nurses, especially intern nurses, in basic knowledge and accurate application of medical terminology. Strengthen the knowledge update of old nurses, strengthen the professional ability of all nurses, and standardize the learning and mastering of nursing medical records. writing. 3.2 Establish a quality control mechanism and establish a sense of responsibility. Each nursing medical record should be self-examined by the department. The nursing department organizes personnel to conduct spot checks to identify problems and resolve them in a timely manner to ensure the accuracy and completeness of each nursing medical record. 3.3 Close cooperation and communication between doctors and nurses. The job of nurses is to implement medical orders. The contents of nursing records and medical records should be consistent. They should strengthen communication with doctors to ensure the quality of nursing records. 3.4 Harmonize the nurse-patient relationship. Nurses should try their best to consider patients, establish a patient-centered nursing concept, strengthen humanized care, and strengthen mutual trust between nurses and patients.