Focusing on Patient Safety and Strengthening the Management of Connotative Quality of Nursing Documents

Abstract

AbstractObjective. To check and analyze the section of contents involving patient safety in the nursing documents and to improve the management of the connotative quality of the nursing documents. Method. A total of five content items, such as a patient's fall, pressure sore, blood transfusion, implementation of medical advice and special records, were checked in combination with the writing requirements of the hospital's nursing documents, based on relevant regulations specified in the Basic Criterion of Documentation of the Medical Record (trial) issued by the Ministry of Health. Result. The problems were that the scores for fall and pressure sore were inaccurate or the measures were not in place. Conclusion. Checking the section of records in the nursing documents involving patient safety, revealed that the inspection of nursing documents cannot become a mere superficial phenomenon of the formal framework and should play a greater role in building up the quality of nursing connotation.