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在记录保存和文档编制方面保持最佳实践。

Maintaining best practice in record-keeping and documentation.

作者信息

Beach Jane, Oates Jennifer

机构信息

West Bromwich.

出版信息

Nurs Stand. 2014 May 13;28(36):45-50. doi: 10.7748/ns2014.05.28.36.45.e8835.

Abstract

This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses' record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses' and other healthcare professionals' attitudes and approaches to this aspect of practice.

摘要

本文结合近期的公众调查与报告、国家对记录保存标准重新燃起的兴趣,以及从纸质医疗记录转向电子医疗文档和数据数字存储所面临的挑战,探讨了记录保存与文档记录的最佳实践。护士与患者关系的性质也在发生变化,这应体现在护士的记录保存实践中。护理计划与评估的协作方法,以及更加强调患者对其所拥有信息的更强主人翁意识,应在护士及其他医疗专业人员对这一实践方面的态度和方法中得到体现。

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