从法律角度分析护理记录缺陷及对策

笔报道从法律角度分析护理记录中的缺陷及对策，护理记录缺陷有；护理记录与医遇记录不符，护理记录与实际措施不符，书写护理诊断相关因素时不慎重，护理记录不及时或随意记录，涂改记录，字迹潦草模糊不清等，一旦发生医疗纠纷，护理记录缺陷将使医院处于被动。提出加强护理人员法律知识，提高自我保护意识；详细询问病史，全面护理体检，及时准确进行记录；避免在护理记录过程中使用涂改液，刮除原字迹及粘贴。

Analysis of nursing records flaws from the angel of law and the countermeasures

The authors report their analysis of nursing records at the angel of law and the countermeasures. They point out flaws in nursing records include: nursing records' not matching the doctors' and not matching the practical measures, carelessness in recording factors related nursing diagnosis, not timely or random recording) altering records, unclear handwriting. Once disputes happen, the flaws in nursing records would set hospital to passivity. They come up with suggestion that we should enhance lawful education among nurses, promote the self-protection sense meanwhile, such countermeasures should be carried out as: detailed inquiries of diseased history, complete nursing body examination timely and accurate recording, avoiding using altering solutions to alter and eliminate the original characters.