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[文件的重要性. 没有记录的被视为没有完成]

Sarah Göpfert1

  • 1Ulsenheimer Rechtsanwälte, Maximiliansplatz 12, 80333, München, Deutschland. Muenchen@uls-frie.de.

Die Anaesthesiologie
|August 9, 2024
PubMed
概括

医生必须优先考虑法律上健全的治疗文件,以保护责任和最佳的患者护理. 这篇文章详细介绍了医疗实践的强制性文件要求,内容和保存.

关键词:
麻醉协议 麻醉协议保存记录的义务 保存记录的义务经过知情同意的同意.医疗责任 医疗责任记忆力 分钟 记忆力 分钟患者记录 患者记录处理文件处理文件处理文件

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Factual:  
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The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
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Role of Communication in the Nursing Process III: Evaluation and Documentation

A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
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