| 英文摘要 |
Nursing records are the routine business documents maintained by nurses during daily practice. They reflect the quality of care and serve as important documentary evidence when medical disputes occur. Nurses should make clear, detailed and complete records of nursing practice as it is not only required by law but also a method of self-protection. Whether the nursing records can present the complete nursing process and whether the nursing processes entered in the records are correct are two important elements of documentary evidence. Nursing records kept by nurses are however sometimes incomplete or inaccurate due to various reasons. This article describes the legal liabilities when medical dispute occurs, elements of negligence and the determination criteria, rules of evidence and burden of proof, then explores the legal function of nursing records and how to ensure they can serve as important evidence for protective purposes. Hopefully, this will help nurses improve their legal knowledge, make them aware of how nursing records are used with regards to burden of proof in lawsuits, and to increase their emphasis and willingness to maintain nursing records. Nursing records can then serve as important evidence to prove nurses’ innocence and provide them with protection. |
