dsh-nurse-record-check

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

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dsh plugin --profile <name> add dsh-nurse-record-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.

Install

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

What it looks like

*Workflow overview: document → rule pack → findings. The examples below use the real command surface.*

What it answers

Examples

The table below is the example set: the first row is the detailed walkthrough, the remaining rows are short cases.

Detailed output

Tool nurse_record_check

Input

~~~yaml records:

• id: REC-0001

kind: general recordedAt: "2026-03-15 09:00" nurseId: N10231

• id: REC-0002

kind: general recordedAt: "2026-03-15 11:00" nurseName: 李护士 ~~~

Output

~~~json { "id": "dsh-nurse-record-check.NR-001.185cc700", "ruleId": "NR-001", "severity": "error", "locator": { "cell": "REC-0002" }, "found": "记录无签名护士标识", "expected": "每条护理记录均应有签名" } ~~~

*Observed from dsh-nurse-record-check/tests/fixtures/NR-001/NR-001-unsafe.yaml*

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 =0.2.1-0 =24.0.0 Platforms · All (plain ESM; no native code, no network, no model call) Tool mode · Works in native and ptc; 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.

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.

1. 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.

1. 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 allow-version dsh-nurse-record-check@0.1.0 --dsh-version --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

PerryLink DSH Plugin Family

This project is part of the DeepSeek Harness plugin family from PerryLink. The roster stays collapsed below so every README keeps a short first screen; expand it to see every row and its status.

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License

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