Pirie Susan
Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill RH1 5RH.
J Perioper Pract. 2011 Jan;21(1):22-7. doi: 10.1177/175045891102100103.
Documentation and record keeping is an important aspect of healthcare practice and perioperative practice is no exception to this rule. For some time now, recording every activity or intervention that a patient receives has assisted with enhancing perioperative practice; equally, it has played a key part in resolving legal and professional incidents that have occurred. There are numerous national guidelines that uphold accurate record keeping as an intrinsic aspect to patient safety (DH 2006, HPC 2008, NMC 2008, Scottish Executive 2008, DH 2009). The intention of this article is to identify and discuss some of the more common errors associated with record keeping which may have a direct or indirect effect on practitioners' misconceptions of using electronic record systems.
文档记录和档案保存是医疗保健实践的一个重要方面，围手术期实践也不例外。一段时间以来，记录患者接受的每项活动或干预有助于提升围手术期实践；同样，它在解决已发生的法律和专业事件中也发挥了关键作用。有许多国家指南将准确的档案保存视为患者安全的一个内在方面（英国卫生部2006年、健康与护理专业委员会2008年、英国国家医疗服务体系护理及助产士管理委员会2008年、苏格兰行政院2008年、英国卫生部2009年）。本文旨在识别和讨论一些与档案保存相关的较为常见的错误，这些错误可能会对从业者使用电子记录系统的误解产生直接或间接影响。
