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护理记录的目标是否反映了对话? : 评估对话记录的准确性

Jessica E Ma1,2, Lindsay Schlichte3, Marie Haverfield4

  • 1Geriatric Research Education and Clinical Center, Durham VA Health System, Durham, North Carolina, USA.

Journal of the American Geriatrics Society
|April 9, 2024
PubMed
概括

护士和社会工作者对护理对话的目标被记录在电子健康记录中. 虽然讨论了大多数组件,但文档准确性各不相同,疾病的理解往往缺失或不正确.

关键词:
提前护理计划 提前护理计划文件 文档 文档 文件 文档关怀的目标 关怀的目标

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