Dimond Bridgit
University of Glamorgan.
Br J Nurs. 2005;14(8):460-2. doi: 10.12968/bjon.2005.14.8.17931.
Record keeping is an integral part of patient care. This article considers the basic principles which should be followed in the light of guidance from the Department of Health, Nursing and Midwifery Council and the Clinical Negligence Scheme for Trusts. Apart from the Mental Health Act 1983 and abortion regulations there are few statutory provisions covering record keeping, but the courts would apply the Bolam Test of the reasonable standard of care to documentation.
病历记录是患者护理的一个重要组成部分。本文根据卫生部、护理及助产士理事会以及信托机构临床过失赔偿计划的指导意见，探讨了应遵循的基本原则。除了1983年的《精神健康法》和堕胎规定外，几乎没有法定条款涉及病历记录，但法院会将博勒姆合理护理标准测试应用于文件记录。
