Nursing Documentation Writing Standards and Management Regulations

Author: Li Zhong, Hunan Provincial Health Department
Publisher:
Publish Date: 2004-07-01
Features: To further standardize the writing and management of nursing documentation in medical institutions in our province, objectively, truthfully, accurately, timely, and completely record the dynamic changes in patients' conditions, promote the improvement of clinical nursing quality, safeguard the legitimate rights and interests of both medical and patient parties, and meet the requirements of the "Medical Malpractice Handling Regulations" and its supporting documents, the Hunan Provincial Health Department organized experts to develop the "Nursing Documentation Writing Standards and Management Measures" (hereinafter referred to as "the Measures") after a year of repeated soliciting opinions, discussions, and revisions. The "Measures" include the admission notification letter, nursing assessment for admitted patients, three-measurement form, temporary medical order form, long-term medical order form, long-term medical order execution form, surgical nursing record, general patient nursing record, critically ill patient nursing record, specialized nursing record, ward nursing handover log, relevant management systems, and nursing documentation quality evaluation standards. It strives to integrate scientific rigor, standardization, innovation, practicality, and operability, reflecting the professional characteristics and academic development level of nursing.