根据2017年《精神卫生保健法》的更新记录做法。
Newer documentary practices as per Mental Healthcare Act 2017.
作者信息
Gajera Gopi, Srinivasa Preeti, Ameen Shahul, Gowda Mahesh
机构信息
Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India.
Department of Psychiatry, St. Thomas Hospital, Changanassery, Kerala, India.
出版信息
Indian J Psychiatry. 2019 Apr;61(Suppl 4):S686-S692. doi: 10.4103/psychiatry.IndianJPsychiatry_110_19.
Medical records form an integral part of patient care. Proper documentation and its maintenance are mandatory as part of the law. It is essential for a treating doctor to document the required details to avoid allegations of negligence. Proper documentation will not only help us to prove that particular services were provided but can also serve as a tool for communication with other professionals. This article draws together the standards and suggests some good clinical practices as per the Mental Healthcare Act 2017.
医疗记录是患者护理的一个组成部分。作为法律规定的一部分，妥善记录并保存记录是强制性的。对于主治医生来说，记录所需细节以避免被指控疏忽至关重要。妥善记录不仅有助于我们证明提供了特定服务，还可以作为与其他专业人员沟通的工具。本文汇总了相关标准，并根据2017年《精神卫生保健法》提出了一些良好的临床实践建议。
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