Show Summary Details
Page of

Documentation in acute care 

Documentation in acute care
Documentation in acute care

Christine Spiers

Page of

PRINTED FROM OXFORD MEDICINE ONLINE ( © Oxford University Press, 2021. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy and Legal Notice).

date: 01 December 2021

Chapter 16 discusses the need for clear, comprehensive, and accurate records of health interventions for patients in acute care, nurses’ professional accountability in relation to their record keeping, and the legislative standards that apply to their practice, and discusses the purpose of documentation and health records, the principles of good documentation, including content and style of the health record, common deficiencies identified in health records, accountability and legal imperatives, ‘Do not attempt resuscitation’ orders, access to health records, electronic health records, the audit of documentation/health records.

Access to the complete content on Oxford Medicine Online requires a subscription or purchase. Public users are able to search the site and view the abstracts for each book and chapter without a subscription.

Please subscribe or login to access full text content.

If you have purchased a print title that contains an access token, please see the token for information about how to register your code.

For questions on access or troubleshooting, please check our FAQs, and if you can't find the answer there, please contact us.