9.22 : 记录的法律指南

The following are a few legal guidelines that a nurse must follow while documenting.

Avoid documenting retaliatory or critical comments about patients or care from other professionals. Such statements show disrespect and may indicate a lack of quality care.

Begin the document by including the date and time for sequencing care and conclude with a signature for accountability.

All written documents should be legible and preferably written in black ink to avoid misinterpretation.

Ensure prompt correction of errors to prevent treatment inaccuracies and any implications of deception or evidence concealment.

Avoid erasing or scratching out errors made while charting, as it may appear that information is being hidden or records are being defaced.

Do not leave blank spaces or lines in the document, as it can allow incorrect information to be added by someone else.

Refrain from documenting for others, as the person entering the data is accountable for the information entered into a patient's record.

Ensure computerized health records are password protected to maintain confidentiality.