dsh-nurse-record-check
护理记录时限、签名与评估表完整性校验（依据《病历书写基本规范》等公开文件，仅提示差异，不作出定性结论）
插件会安装到这里；不确定时保持 web。
npx -y @deepseek-ai/dsh plugin --profile web add dsh-nurse-record-check@0.2.4Nurse Record Check 以 dsh-nurse-record-check 发布，当前版本为 0.2.4。Plugin Hub 会校验它的 manifest，并保存精确安装来源，便于复现安装结果。
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.
Terminal demo of dsh-nurse-record-check: real output over its NR-007 fixture
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.
| 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. |
| 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.
| 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 |
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.
dsh plugin --profile <name> add dsh-nurse-record-check
dsh --profile <name> --dump-config | grep 'dsh-nurse-record-check'
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 |
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 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:
NR-012 therefore ships with an empty threshold.NR-008 therefore ships with an empty threshold.NR-010 rests on the
general duty in Article 3 and is capped at info for that reason.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-riskskipped 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.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
Apache License 2.0 © 2026 dsh-nurse-record-check contributors.