First, the causes and countermeasures of problems in nursing document writing.

1. Problems in writing nursing documents

(1) Incomplete nursing records: Because nursing documents are incomplete, they can't reflect the dynamic changes of illness and the continuity of treatment and nursing, so there are potential disputes.

(2) Infusion card records and intravenous drip are inconsistent with the doctor's advice.

(3) There is no nurse's signature or scribble signature after the infusion card is treated and changed.

(4) The temperature list has individual blood pressure, weight, admission and discharge marks.

(5) The eyebrow column of the first visit nursing record is incomplete, and the evaluation is not comprehensive, accurate and inconsistent with the reality. I didn't finish writing the specific contents within 4 hours after admission.

(6) The skin test of penicillin was inconclusive, and the drug requiring allergy test was blindly executed, but the skin test or exemption prescription was not prescribed.

(7) Nursing records are not timely and irregular.

(8) The nursing level is inconsistent with the nursing record.

(9) Long-term and temporary orders are not signed by the executive nurse or teacher.

(10) The indwelling needle has no continuous observation record, and the puncture site has no injection time record.

(1 1) When writing documents, a few nurses' handwriting was illegible.

(12) There is no nursing plan for critically ill patients or the nursing plan is too simple.

(13) The rescue record is not standardized and timely.