Gruber M, Gruber J M
Gastroenterol Nurs. 1990 Spring;12(4):255-9. doi: 10.1097/00001610-199004000-00008.
Documentation is an elemental to nursing as wound care and vital sign assessment. This article examines the reasons and techniques for accurate and complete documentation in a medical record. Several examples of nursing malpractice involving improper documentation are described. Abbreviations, flow sheets, incident reports, late entries, errors and content are included in the discussion presented.
记录与伤口护理和生命体征评估一样，是护理工作的基本要素。本文探讨了在病历中进行准确完整记录的原因和技巧。文中描述了几起因记录不当而导致护理失误的案例。讨论内容包括缩写、流程表、事件报告、补记、错误及记录内容。
