Results: The questions in nursing records included discontinuous content,lack of nursing content,less individuation,inaccurate express,overdue and uncomplete records and inaccurate medical terms.

• 结果:护理记录单书写中存在的缺陷依次为内容缺乏连续性、记录治疗内容多护理内容少、缺乏个性化、语言表达不准确、记录不及时、不全面、使用医学术语不恰当。