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Abstract: The convenient sampling methods was used to collect nursing records with writing defects in the CCU from August 2012 to June 2014, and were interviewed to explore the possible reason. The reasons of nursing record defects mainly included the item missing, nonstandard recording, the routine nursing record not detailed, wrong character, inconsistently recording,lack of specialized subjects in the recording. The properly reasons were nurses’ legal consciousness faint, lack of understanding of the importance of nursing recording, lack of the specialized nursing knowledge. Nurses’ work were busy and trivial, resulting in nursing records not in time, and supplement the record was easy to cause loss or distortion of the items. Electronic medical record system needs to be further improved. Strengthening the study of legal knowledge and professional nursing foundation, perfecting the information system, can effectively control the nursing records defects in the busy nursing daily work.
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http://www.zghlgl.com/EN/Y2015/V15/I8/935
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