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伤口记录:管理风险。

Wound documentation: managing risk.

作者信息

Brown Gregory

机构信息

Dallas Veterans Medical Center, Dallas, TX, USA.

出版信息

Adv Skin Wound Care. 2006 Apr;19(3):155-65, quiz 165-7. doi: 10.1097/00129334-200604000-00011.

DOI:10.1097/00129334-200604000-00011
PMID:16639222
Abstract

PURPOSE

To provide the physician and registered professional nurse with an understanding of consistent wound documentation and the potential for legal issues to arise.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in better understanding and improving policies and procedures related to wound documentation.

OBJECTIVES

After reading the article and taking the test, the participant should be able to: 1. Discuss wound assessment and documentation relative to current practices and potential legal implications. 2. Describe recommendations to improve the consistency and accuracy of wound assessment and documentation.

摘要

目的

使医生和注册专业护士了解伤口记录的一致性以及可能出现的法律问题。

目标受众

本继续教育活动面向有兴趣更好地理解和改进与伤口记录相关政策和程序的医生和护士。

目标

在阅读本文并参加测试后,参与者应能够:1. 讨论与当前实践和潜在法律影响相关的伤口评估和记录。2. 描述提高伤口评估和记录的一致性和准确性的建议。

相似文献

1
Wound documentation: managing risk.伤口记录:管理风险。
Adv Skin Wound Care. 2006 Apr;19(3):155-65, quiz 165-7. doi: 10.1097/00129334-200604000-00011.
2
The art of skin and wound care documentation.皮肤与伤口护理记录的艺术。
Home Healthc Nurse. 2005 Aug;23(8):502-13; quiz, 514-5. doi: 10.1097/00004045-200508000-00010.
3
The art of skin and wound care documentation.
Adv Skin Wound Care. 2005 Jan-Feb;18(1):43-53; quiz 54-5. doi: 10.1097/00129334-200501000-00017.
4
"Ladies & gentlemen of the jury, I present ... the nursing documentation".陪审团的女士们、先生们,我呈上……护理记录文件。
Nursing. 2006 Jan;36(1):56-62; quiz 63-4. doi: 10.1097/00152193-200601000-00043.
5
Concept analysis: malpractice and modern-day nursing practice.概念分析:医疗失误与现代护理实践
Nurs Forum. 2009 Jan-Mar;44(1):2-10. doi: 10.1111/j.1744-6198.2009.00121.x.
6
Long-term care demands precise documentation.长期护理需要精确的文件记录。
Nurs Manage. 2000 Nov;31(11):23-4. doi: 10.1097/00006247-200011000-00017.
7
When is it appropriate to photograph a patient's wound?
Adv Skin Wound Care. 2006 Jul-Aug;19(6):304, 6. doi: 10.1097/00129334-200607000-00008.
8
Nursing documentation standards and practice in cases of sexual assault.
Oreg Nurse. 2006 Feb;71(1):2.
9
Using self-study modules to improve wound care documentation by the staff nurse.使用自学模块来改善护士对伤口护理的记录。
J Nurses Staff Dev. 2009 Jul-Aug;25(4):E1-4. doi: 10.1097/NND.0b013e3181ae1445.
10
Teaching the patient with a chronic wound.
Adv Skin Wound Care. 2005 Sep;18(7):379-87, quiz 388-90. doi: 10.1097/00129334-200509000-00012.

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