Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 208

When making an entry in a record or documenting care outcomes, the nursing associates must ensure that entry that they are making in the record is factually correct. Only record what you, as the nursing associate, see, hear or do. Using emotive statements can hinder the nursing associate and other readers of records from making objective decisions regarding the patients and their care.

Another example would be if a patient is incontinent of urine and faeces, the written record should be identifying this rather than simply stating that the patient has been incontinent as this again does not fully and accurately convey or report on the needs of that patient. This would also have implications for future reviews to be completed; they may not be accurate as the information about the type of incontinence is not available to the next person undertaking a review. The subsequent reviews are also recorded, and as such, the principles of accuracy and clarity will also apply.