dsh-nurse-record-check — Nursing record timeliness, sign-off and assessment-form completeness check

dsh-nurse-record-check reads a machine-readable export of one inpatient episode — nursing entries, medical orders and completed assessment forms — and checks the timeliness, sign-off and assessment-form record of that nursing documentation (护理记录), reporting literal mismatches against cited clauses: that every nursing entry leaves a traceable recorder and a time, that every date and time is written in 24-hour form and can be read, that a rescue record's time is precise to the minute and its note is written up within 6 hours of the rescue ending, that a temporary order carries an execution time and the executing nurse's signature and that a cancelled order records its cancellation, that the first nursing assessment and the documentation frequency meet the thresholds the institution configures, that fall-risk and pressure-injury assessment forms are on file, and that the rounds interval matches the graded-nursing guidance for the care level the record states. A check that cannot run is listed in skipped instead of passing.

What it looks like

Real output from this plugin over its own NR-007 test fixture — not a mock-up. The rule pack ships no invented quotations, so a finding names both the clause it applied and the fact that the clause text was not obtained.

What it answers

You ask	What it answers
A nursing entry came out of the ward system with no signing nurse. Is that reported?	Yes. NR-001 reports every nursing entry that leaves no recorder identifier, and also a nurseId that does not match the configured staff-number pattern. It checks that the material leaves a recorder mark and a time, not how the electronic signature is technically implemented.
One time value in the export will not parse. What does the rule do with it?	NR-002 reports the value and expects a time written in 24-hour form and readable as YYYY-MM-DD HH:mm. A record whose time cannot be parsed is then left out of the later time-window comparisons, so it surfaces here rather than as a deadline finding — the rule checks that the time can be read, not that it is the true time.
Our rescue record gives the date of the rescue but no clock time.	NR-003 reports a rescue record whose time is precise only to the day, because the time of a rescue must be precise to the minute. The pack notes that the two documents it cites do not require the same thing — one requires 抢救时间 to the minute, the other the 记录时间 — and presents them together with each source marked separately.
The rescue note was written up the next morning. Is that late?	NR-004 compares the recorded time with rescueEndedAt and reports a gap longer than 6 hours; a note written before the rescue ended is reported too. With no rescueEndedAt there is nothing to compare, and the check reports that it could not run instead of passing.
A temporary order was carried out, but the executing nurse's signature column is blank.	NR-005 reports a temporary order whose execution record is missing the execution time or the executing nurse's signature. It applies to 临时医嘱 only — the long-term order sheet carries different content items and must not be read alike — and it does not check how long after execution the signature was made, because the pack found no signature deadline.
Some rules come back as skipped rather than passing. What does that mean?	It means the check did not run, not that it passed. NR-008 and NR-012 ship with their thresholds empty (maxAfterAdmission, intervalHours), because the pack found no national threshold it could apply to nursing records — and it records that the 24 hours it did find belongs to the 入院记录 written by a physician and must not be carried over to the first nursing assessment — while NR-011 likewise reports itself in skipped for 特级护理, where the guidance states no interval, and when there are fewer than two rounds entries to compare.

Standards it follows

Document	Number	Cited by rules
《电子病历应用管理规范（试行）》	国卫办医发〔2017〕8号	NR-001, NR-006, NR-010
《病历书写基本规范》	卫医政发〔2010〕11号	NR-002, NR-003, NR-004, NR-005, NR-007, NR-010, NR-012
《医疗质量安全核心制度要点》	国卫医发〔2018〕8号	NR-003, NR-004
《卫生部办公厅关于在医疗机构推行表格式护理文书的通知》	卫办医政发〔2010〕125号	NR-005
《护理分级标准》	WS/T 431—2023（全部代替 WS/T 431—2013；推荐性卫生行业标准，2024-02-01 施行）	NR-008
《进一步改善护理服务行动计划（2023—2025年）》	国卫医政发〔2023〕16号	NR-009
《三级医院评审标准（2020年版）》	国卫医发〔2020〕26号	NR-009
《综合医院分级护理指导原则（试行）》	卫医政发〔2009〕49号	NR-011

Boundary: this plugin checks the timeliness, sign-off and assessment-form record of nursing documentation (护理记录) in an inpatient episode. It is not dsh-medrec-qc (which checks the front sheet of the medical record and its internal contradictions), not a nursing-quality scorecard, and not a clinical decision aid. It reads a machine-readable export and reports literal mismatches against cited clauses; it never decides whether an episode of care was appropriate.

Compatibility

Surface	Status
Harness	Peer range >=0.1.2-rc.1 <0.2.0 || >=0.2.0-0 <0.3.0 — verified to accept both 0.2.0-rc.2 and 0.2.1-alpha.1. engines.dsh is deliberately not declared: it has no reader and cannot reject a host
Node	`^22.19.0
Platforms	All (plain ESM; no native code, no network, no model call)
Tool mode	Works in native, ptc and both; for a directory of episodes use ptc to pay schema cost once

What it does

Registers the nurse_record_check tool. It reads one patient episode — nursing entries, medical orders and assessment forms — applies a versioned rule pack, and returns a report whose every finding names the clause it came from.

Rule	Check	Severity
NR-001	every nursing entry carries a traceable recorder (id and time)	error
NR-002	every date/time in the material is written in 24-hour form and is readable	error
NR-003	rescue-note times are precise to the minute	error
NR-004	a rescue note is written up within 6 hours of the rescue ending	error
NR-005	a temporary order carries an execution time and the executing nurse's signature	error
NR-006	an execution time is not earlier than the order's placement time	info
NR-007	a cancelled order records its cancellation and signature	error
NR-008	the first nursing assessment meets the locally configured window	info
NR-009	fall-risk and pressure-injury forms are on file	warn
NR-010	a record's timestamp is not earlier than the event it documents	info
NR-011	the rounds interval matches the graded-nursing guidance for the care level	error
NR-012	documentation frequency meets the locally configured policy	info

Two rules ship unconfigured on purpose, because no national threshold exists for them. They report themselves in skipped and never silently pass.

Install

dsh plugin --profile <name> add dsh-nurse-record-check
dsh --profile <name> --dump-config | grep 'dsh-nurse-record-check'

Configuration

Every tunable lives in the Schemastery schema in src/config.ts, so it can be changed from cordis.yml without editing code.

Key	Type	Default	Description
rulesFile	string	rules/nurse-record.yaml	Rule-pack path, relative to the package root
disabledRules	string[]	[]	Rule ids to stop running; each appears in skipped
onlyRules	string[]	[]	Run only these rule ids; empty runs every rule
skipNotes	string	""	Note appended to every skipped reason
timeoutMs	number	120000	Cooperative tool timeout budget

Material format

The tool accepts JSON or YAML. A docx or xlsx binary is not parsed: ward systems export either a JSON payload or a flat table, and the contract below is what a caller (or your own converter) fills in. Fields are optional at the reader level and validated by the check engine, so a partial export produces findings about the missing parts instead of a crash.

target: 内科三病区 2026-03-15 护理记录
episode:
  admittedAt: "2026-03-15 08:00"   # drives NR-008
  careLevel: level-2               # drives NR-011 / NR-012
  patientLabel: 样本患者甲
records:
  - id: REC-0001
    kind: rescue                   # rescue | general | rounds | handover | discharge | other
    recordedAt: "2026-03-15 14:20"
    rescueEndedAt: "2026-03-15 13:50"
    nurseId: N10231
    orderId: ORD-1001              # links a record to an order for NR-010
orders:
  - id: ORD-1001
    type: temporary                # temporary | long-term
    orderedAt: "2026-03-15 10:00"
    execution: { executedAt: "2026-03-15 10:20", nurseId: N10231, outcome: executed }
    cancellation: { cancelledAt: "2026-03-15 10:10", reason: 患者外出检查 }
assessments:
  - kind: 跌倒坠床风险评估          # matched through the shared synonym map
    completedAt: "2026-03-15 09:40"

Rule sources

Rule data lives in rules/nurse-record.yaml and is separate from code. Every rule carries a document, a document number, a clause in the source's own numbering, a verbatim excerpt and the URL the excerpt was read from. The loader enforces three things: an excerpt must be a real quotation, an excerpt under eight characters is rejected, and a check whose basis is only a general principle (kind: derived-from-principle, capped at warn) or a local policy (kind: institutional-configuration, capped at info) may never be declared error. A pack that overstates its basis fails to load instead of producing a confident-looking report.

Clause numbers were checked against full texts of: 《病历书写基本规范》（卫医政发〔2010〕11号）, 《综合医院分级护理指导原则（试行）》（卫医政发〔2009〕49号）, 《电子病历应用管理规范（试行）》 （国卫办医发〔2017〕8号）, 《医疗质量安全核心制度要点》（国卫医发〔2018〕8号）, 《进一步改善护理服务行动计划（2023—2025年）》（国卫医政发〔2023〕16号） and 《护理分级标准》（WS/T 431—2023）.

Three findings from that verification shaped the pack, and are recorded here so a reviewer can see what was deliberately not claimed:

1. No national documentation-frequency rule exists. WS/T 431—2023 deleted the "implementation requirements" chapter of its 2013 edition, and the graded-nursing guidance states a rounds interval, never a documentation frequency. NR-012 therefore ships with an empty threshold.
2. No national deadline exists for the first nursing assessment. The 24-hour rule in Article 17 of 卫医政发〔2010〕11号 governs the physician's admission note, not a nursing assessment; applying it here would be a mis-citation. NR-008 therefore ships with an empty threshold.
3. No clause forbids a record time earlier than an execution time. NR-010 rests on the general duty in Article 3 and is capped at info for that reason.

Troubleshooting

• The plugin installs but the tool never appears. Check main resolves to lib/index.mjs and that pnpm run build produced it; a wrong main makes the loader skip the entry silently.
• dsh plugin add refuses the package as incompatible. The peer range covers 0.1.x and 0.2.x; if your runtime sits outside it, grant an explicit exemption: dsh plugin --profile <name> allow-version dsh-nurse-record-check@0.1.0 --dsh-version <runtime> --accept-risk
• A rule you expected did not run. Read the skipped array; it names the rule and why. Rules NR-008 and NR-012 stay skipped until their thresholds are configured.
• check reports manifest-peers as failed. The static checker compares against a hard-coded peer range that predates the 0.2 line. The runtime enforces peer compatibility at install time, so the declared range is the correct one; this is a known upstream issue in dsh-plugin-dev.
• Times look shifted. All arithmetic is wall-clock on the strings you supply, with no time-zone conversion: a record means the local time that was written down.

Development

pnpm install
pnpm run typecheck   # tsc --noEmit
pnpm test            # vitest, paired fixtures per rule
pnpm run build       # tsdown -> lib/index.mjs + lib/index.d.mts
node ../scripts/sync-shared.mjs dsh-nurse-record-check   # refresh src/shared from ../_shared

License

Apache License 2.0 © 2026 dsh-nurse-record-check contributors.