Allen A
J Post Anesth Nurs. 1994 Jun;9(3):172-3.
Documenting medical records is often done hurriedly; it is a last responsibility before the patient is discharged, sometimes after the shift has actually ended. What seemed so clear at the time it was written may be barely legible, unbelievably incomplete, and perhaps legally indefensible later. The patient's chart is a permanent legal record that can powerfully defend or easily discredit the nurse when questions arise. A documentation review could be time well spent.
记录病历往往很仓促；这是患者出院前的最后一项任务，有时甚至是在班次实际结束之后才进行。当时写的时候看起来很清楚的内容，之后可能几乎难以辨认、难以置信地不完整，而且在法律上可能站不住脚。患者的病历是一份永久性法律记录，当出现问题时，它可以有力地为护士辩护，也可以轻易地使护士名誉扫地。进行一次病历记录审查可能是很值得花时间的。
