The art of recording patient care information.
Clinical records are the main source of information and evidence used for dealing with complaints, claims and clinical incident investigations. The accuracy, depth and professionalism of the clinical notes all add to their credibility.
Pennels
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East Gloucestershire NHS Trust, Cheltenham.
D004282:Documentation; D006801:Humans; D009737:Nursing Records; D009741:Nursing Staff, Hospital; D011787:Quality of Health Care