McArdle E J, Allain L A
J Post Anesth Nurs. 1991 Aug;6(4):246-54.
Documentation demonstrates that nursing standards of care have been met. To be an effective tool, a record must be complete and concise. A request to develop PACU care plans became the impetus to revise the PACU record. Perioperative information and physical assessments are data required to formulate individualized plans. Development and implementation of a comprehensive record was a positive outcome of a lengthy but interesting and worthwhile project.
文件证明护理标准已得到满足。要成为一个有效的工具，记录必须完整且简洁。制定PACU护理计划的要求成为了修订PACU记录的动力。围手术期信息和身体评估是制定个性化计划所需的数据。一份全面记录的开发和实施是一个漫长但有趣且有价值的项目的积极成果。
