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Documentation in acute care 

Documentation in acute care
Chapter:
Documentation in acute care
Author(s):

Christine Spiers

DOI:
10.1093/med/9780199564385.003.16
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date: 30 September 2020

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.

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