Legal and medical nursing aspects of documentation, recording and reporting.
This article deals with the importance of documentation, recording and reporting as a means of communication in daily medical and nursing practice. It points out the common deficiencies in this respect and describes the legal, clinical, medical and nursing implications of proper reporting. The medical staff is often not sufficiently aware of the importance of accurate reporting. The inadequate compiling and incorrect reading of medical records can jeopardize patients' rights to quality service.
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Department of Nursing, Tel Aviv University, Israel, Tamar Ben-Or.
Ben-Or
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D003142:Communication; D005260:Female; D005568:Forms and Records Control / Q000331:legislation & jurisprudence / Q000592:standards; D006801:Humans; D007557:Israel; D008297:Male; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards; D009737:Nursing Records / Q000331:legislation & jurisprudence / Q000592:standards; D011787:Quality of Health Care