【摘要】通过对本院病历质控检查或随机抽查中发现的一些缺陷和问题，进行归纳和总结，并提出多种改进对策。认为记录单签字是护理文书书写规范的要求，是医疗行为的证据，是护理服务的准则，具有法律依据，有现实意义和法律意义。

    【关键词】医嘱执行卡 签字 缺陷 对策

    In the long-term doctor’s advice execute card signature fence exists flaw and improvement countermeasure

    Li Xiaoping

    【Abstract】Through controls some flaws and the question to this courtyard medical record nature which in the inspection or the stochastic spot-check discovered，carries on the induction and the summary，and proposes the many kinds of improvements countermeasure. Thought the label signature is nurses the copy clerk writing standard the request ......