1, nursing documents are written records formed by nurses in the process of nursing. Specifically, it is the original written record of nursing staff observing patients' condition and nursing, recording the whole process of patients' treatment, reflecting the evolution of patients' condition, which has important legal significance and unquestionable burden of proof for solving medical accidents.
2. Nursing records can not only directly reflect the observation ability and professional level of nurses, but also be an objective basis for evaluating nursing quality.
3. It also accumulates information for nursing scientific research and is a good material for clinical teaching.
Legal significance of nursing documents
1. The handwriting is unclear and has been altered. When medical incidents are controversial, there is a defect of insufficient proof, and the relevant laws explain that nurses are irresponsible in their work and hospital documents lack authenticity.
2. The condition assessment is not true. Due to the lack of communication between medical staff, the records of doctors and nurses are obviously different, the description of illness in nursing records is inconsistent with the doctor's course record, and the rescue measures, medication and death time are also inconsistent. This is the key legal responsibility of insufficient evidence in potential medical malpractice disputes.
3. Omitting objective data. For example, nurses who have long-term doctor's orders sometimes miss the signing after implementation, and may be supplemented by their nurses after examination, and there are objective data recording errors in nursing records. For example, when copying long-term doctor's orders or infusion cards, mannitol 150ml is written as 250ml, and critical patients sometimes miss vital signs as required. These are obviously related to legal responsibility.
4. The time stipulated in the doctor's advice is inconsistent with the time when the nurse carries out the doctor's advice. Doctor's advice is the legal basis for nurses to treat patients. Sometimes doctors forget to prescribe the wrong time, and nurses forget to check the execution time. Or the doctor did not give it to the nurse in time after prescribing the doctor's advice; After signing, the operation was postponed, and the interval between the nurse's execution time and the doctor's advice was too long. This lurks the legal responsibility of delaying rescue and timely treatment.
5. The record of nursing measures is incomplete, the key points of nursing records are not prominent, or the records are not targeted and incoherent, which fails to dynamically reflect the patient's condition, treatment and nursing effect. When rescuing critically ill patients, it was not recorded in time because of busyness or negligence, which was suspected of delaying the rescue and treatment of patients. Nursing documents record the whole process of patients' treatment, nursing and rescue, which is an important legal basis.
Concept of nursing documents: nursing documents are the general name of words, symbols, charts and other materials formed by nurses in the process of medical nursing activities.
Composition of nursing documents: as an important part of medical records, nursing documents include temperature list, doctor's order list and nursing record list. In view of the specific situation of each province, medical orders include long-term and temporary medical orders or execution of medical orders. Nursing records include ordinary care records, critical care records, surgical care records and specialist care records.
legal ground
Basic norms of medical record writing
Article 2 Medical record writing refers to medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing.
The act of obtaining relevant information, summarizing, analyzing and sorting it out to form a record of medical activities.
Article 3 The writing of medical records shall be objective, true, accurate, timely, complete and standardized.
Article 6 Medical terms shall be standardized in the writing of medical records, with neat handwriting, clear handwriting, accurate expression, fluent sentences and correct punctuation.
Article 7 When typos appear in the process of writing medical records, they shall be marked with double lines, and the original records shall be kept clear and readable, with the time of revision indicated and signed by the reviser. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting.
The superior medical staff has the responsibility to review and modify the medical records written by the lower medical staff.