摘要： 护理文书是对患者住院过程中疾病的治疗、护理、转归、预后的真实反应,一旦发生医疗纠纷或事故时,具有法律依据的作用。本文试图按照《医疗事故处理条例》(以下简称《条例》)的要求,从护理文书记录中存在(潜在)的法律问题进行探讨,以求提高对《条例》的理解和认识,加强护理人员法制观念,进一步规范护理文书的书写,减少或消除不安全的隐患,确保患者就医安全。

Abstract: Nursing documents are the real reflection of the treatment, nursing, conversion and prognosis of the disease when patient is hospitalized. Once there is a medical dispute or medical accident, nursing documents would be the legal evidence. The article expl