Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 207

The language used in records must be unambiguous in its meaning. This requires that it is factual and not open to interpretation in any way which could lead to confusion and ultimately could result in a patient not receiving the care they need or care that may cause them harm. If a patient, for example, has had their vital signs measured and recorded every 15 minutes, then this frequency must be recorded rather than a simple entry to state that the patient’s vital signs have been measured. The fact that the reader now knows that the vital signs have been recorded every 15 minutes conveys a message that the patient’s needs are such that they require close monitoring.