Dimond Bridgit
University of Glamorgan.
Br J Nurs. 2005;14(10):568-70. doi: 10.12968/bjon.2005.14.10.18106.
This article discusses many of the common mistakes which occur in record keeping including absence of clarity, failure to record action taken to meet an identified problem, missing information, significant spelling mistakes and failures in communication. It also considers some of the lessons on record-keeping standards which can be drawn from reports of the Health Service Commissioner (Ombudsman).
本文讨论了记录保存中出现的许多常见错误，包括记录不清晰、未记录为解决已发现问题而采取的行动、信息缺失、严重拼写错误以及沟通失误。它还探讨了一些可从卫生服务专员（监察员）报告中汲取的关于记录保存标准的经验教训。
