由于医疗事故处理条例及举证责任倒置规定的出台,使得护理记录十分重要,护理记录中的每一个字、每个符号都代表了一份法律责任,每句话都可能作为法律依据。护理文件也是医疗诉讼中最重要的证据之一,护理记录是护理人员对病人的病情观察和实施护理的原始文字记载。由于一般护理记录的书写处在刚刚起步阶段,在日常的护理记录中仍存在着一些问题,需要引起足够的重视。 Due to the promulgation of medical malpractice regulations and the reversal of the burden of proof, nursing records are very important. Every word in the nursing records and each symbol represent a legal liability, and every sentence may serve as the legal basis. Nursing documents are also one of the most important evidences in medical litigation. Nursing records are the original written records of nursing staff’s observation and implementation of nursing care. As the writing of general nursing records is still in its infancy, there are still some problems in daily nursing records that need to be given sufficient attention.