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如何进行有效的记录保存和文件编制。

How to undertake effective record-keeping and documentation.

机构信息

Faculty of Health and Life Sciences, De Montfort University, Leicester, England.

出版信息

Nurs Stand. 2021 Mar 31;36(4):31-33. doi: 10.7748/ns.2021.e11700. Epub 2021 Mar 15.

Abstract

Effective record-keeping and documentation is an essential element of all healthcare professionals' roles, including nurses, and can support the provision of safe, high-quality patient care. This article explains the importance of record-keeping and documentation in nursing and healthcare, and outlines the principles for maintaining clear and accurate patient records. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.

摘要

有效的记录保存和文件归档是所有医疗保健专业人员(包括护士)角色的重要组成部分,它可以支持提供安全、高质量的患者护理。本文解释了护理和医疗保健中记录保存和文件归档的重要性,并概述了维护清晰准确的患者记录的原则。 反思性实践:“如何做”文章可以帮助更新您的实践并确保其保持基于证据。将本文应用于您的实践。反思并撰写一份简短的说明。

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