The significance of writing nursing documents [1, 2]
2.1 Assessing patients Nurses can obtain first-hand information about changes in the patient's condition, treatment, care and response. The information obtained from the records helps nursing staff identify patient problems and formulate targeted nursing measures. It is also an important reference for doctors to understand the progression of the disease, make a clear diagnosis, and formulate and adjust treatment plans.
2.2 Survey and Research Complete nursing records are important data for nursing research. They also provide statistical raw data for epidemiological research, infectious disease management, etc.
2.3 Teaching materials A complete nursing record allows nursing students to see the specific application of nursing theory in practice and is the best material for teaching.
2.4 Assessment Basis Nursing documents can reflect the nursing level of a hospital to a certain extent. They are important information materials for hospital nursing management and are also one of the reference materials for the assessment of nursing staff in the hospital grade review.
2.5 Legal basis Nursing documents have legal effect and are legally recognized evidence. In court, it can be used as the legal basis for medical disputes, medical malpractice, personal injuries, insurance claims, criminal cases, etc.