Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 211

Many computer programmes used for record‐keeping contain spell checkers, although these should not be relied upon as when words are not spelt correctly but the misspelled word is still a word, the spell checker would overlook this. For example, if the word ‘loose’ was mistyped as ‘lose’, this would have a different meaning, but as it may be a proper word, the mistake would be undetected by the computer. This highlights the importance of proofreading the entries, as other healthcare and social care professionals reading this record would assume that the patient had lost their bowels completely rather than having diarrhoea which is the intended message.

In written records, there are no spell checkers that can be used. Few nursing associates or registered nurses would be able to ever say that they had never made a spelling mistake or typing error within a record; how these are managed and minimised can improve the accuracy and clarity of the record. In some instances where perhaps a drug name is being recorded or a diagnosis is being written, it is essential that the word is spelt correctly. In these instances, it is a good practice to use a good nursing or medical dictionary. Many of these dictionaries are available online and are easily accessible through apps on mobile devices. The earlier guidance regarding making corrections is important so that the reader can see that the misspelled word has been changed and that the crossed‐out word was nothing more than a correction and not an attempt to alter or falsify a record. While discussing clarity of a record, it has to be considered that a record should be timed and not just dated to demonstrate that care has been provided and there is sequential logic to the entry.