Exploring common deficiencies that occur in record keeping.
This article discusses many of the common mistakes which occur in record keeping including absence of clarity, failure to record action taken to meet an identified problem, missing information, significant spelling mistakes and failures in communication. It also considers some of the lessons on record-keeping standards which can be drawn from reports of the Health Service Commissioner (Ombudsman).
Dimond
Bridgit
B
University of Glamorgan.
D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control; D017408:Guidelines as Topic; D006801:Humans; D009731:Nursing Audit; D009737:Nursing Records / Q000592:standards*; D012308:Risk Management / Q000592:standards; D016636:Telefacsimile; D013689:Telephone