2010•Guoji yiyao weisheng daobaoRequires access
Comparison of content defects between real-time and summary nursing records
LU Shao-ping, Huigen Huang, Yongneng Xu, Xiao-xiao Ren, Ping-you Zhang
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Abstract
Objective To evaluate and compare content defects of real-time and summary nursing records. Methods 390 pieces of real-time nursing records and 390 pieces of summary nursing records were randomly reviewed. The defects of contents in timeliness, accuray, authenticity, continuity,and repetition were compared between the two groups. Results The group with real-time nursing records had a lower defect rate than the group with summary nursing records (P<0.01). Real-time records had fewer defects in timeliness, accuracy, authenticity, continuity, and repetition than summary records (P< 0.05). Conclusions The way of real-time writing nursing records can reduce the occurrence of content defects and is superior to that of summary writing in improving the quality of nursing record.
Key words:
Summary nursing records; Real-time nursing records; Contents of the nursing records; Defects