Quality Analysis on Nursing Records of Severe Patients in Respiration Department

Objective To discuss the changes of nursing records on the severe patients in respiration department so as to find out the existing problems and improve the quality of nursing records.Methods One hundred and twenty nursing records which were randomly selected from 468 severe patients' discharge nursing records from Jan.2003 to Dec.2008 were analyzed retrospectively and individually.Results The nursing documents were more objective and concise in the years after 2006.The pages of nursing files were far more standard and neater.The types of record sheets were obviously decreased.The defects of special department records,omission of major nursing observations and inconsistency of medical and nursing records were observed in the nursing materials.Conclusion According to the requirement of The Basic Criteria for Medical Records Documenting,the quality of nursing records can be improved by perfecting the unique nursing records of severe patients in respiration department,and by training nurses in writing skills.