Analysis of the quality of nursing records and its managing measures

Objective To standardize clinical nursing precedure and ensure safe nursing.Methods One thousand and one hundred eight three inpatient's pigeonholed medical records from January 2006 to Novemder 2007 were spot-checked for quality evaluation.Results 1.With regard to quality of the various nursing files,the highest rate of score deduction was found in the medical order sheet and in the nursing records of ordinary patients,while the lowest rate was shown in the nursing records of critical patients.The highest defect was shown in the nursing records of ordinary patients and in the temperature sheets,the lowest rate was in the nursing records of critical patients.The χ2 test showed significance in the comparison of defect.2.With regard to quality analysis of the various kinds of nursing records of ordinary patients,the highest rate of score deduction was in the general nursing records,while the lowest rate was shown in the admission nursing evaluation sheets.The highest defect was in the general nursing records,the lowest was in the admission evaluation sheets.Conclusion The training of writing standardized high quality nursing material is important to improve the quality of nursing records and protect the rights and interests of both medical worker and patients.