he nursing practice the nurses pay more attention on patients physical condition omit related legal problem for example record nursing lag behind or incomplete.The nursing record is inconsistent with clinical record or nursing level is inconsistent with physicians decision.Sometimes nurses execute lagged behind doctors prescription.The patients condition changed but nurses and doctors failed to react in time which often happened in critical case or in night duty.In this study we found that the nursing recording exist defect such as omitting record or incomplete record;temporary prescription signed by non-execution nurses;nursing diagnosis didnt occur;different record wrote by the same nurse to meet inspection need;record temperature in advance when the patient are discharged the temperature record still exist.A case was died but record was normal breathing and blood pressure 2 level nursing to 3 level.
The regulation for settlement of medical accident stipulates the patients have the right to copy the medical ecord altering fabricating concealing destroying seizing and stealing record are strictly forbidden.The Supreme Peoples Court interprets the regulation for settlement of medical accident one of the most important rule is show evidence by medical professionals to prove they correctly complete the operation.But recording not in detailed and fabricate set risks to complaints. 3.3.5 Communication gap between patients and nurses By now the holistic nursing is not expand widely a communicating gap exists between patients and nurses.Some nurses communicate unskillfully with patients such as do not explain nursing operation to patients.
3.3.6 Unskilled operation In the rural area a large number of nurses are non-nursing speciality they are lack of theoretical knowledge professional technic and operation skill.In emergent situation they can not meet the requirements to h
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