Faculty of Health and Life Sciences, De Montfort University, Leicester, England.
Nurs Stand. 2021 Mar 31;36(4):31-33. doi: 10.7748/ns.2021.e11700. Epub 2021 Mar 15.
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.
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。
