骨科护理文件书写缺陷分析及对策 关键词】骨科;护理文件缺陷;对策 [gap=825]Key words】Department of Orthopedic; Nursing record defects;Countermeasures
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目的针对护理文件书写存在的缺陷，进行规范管理，从而提高护理文件书写质量。
Objective According to the standardized management in allusion to the existent defect in the nursing document, thus to improve the nursing document writing quality.
结果护理文件书写缺陷原因主要与护理人员少、责任心及法律意识不强有关。
Result the defects in nursing documentation were mainly related to the deficiency of nursing staff, the weakness of sense of responsibility and legal awareness among nurses.
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