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A patient's record is a written document. It can keep information about a patient's health permanently.
患者的病历是一份书面文件。里面永久性地记载这患者的健康信息。
If it is well written and organized, the nurse may take care of the patient more effectively.
如果病例内容清晰、有条理，护士能够更有效地照顾病人。
There are 6 useful points to follow to make sure the quality of reporting.
为确保病历质量，护士应当遵循六点注意事项。
1. Accuracy. Information must be correct. The nurse should separate clearly objective data from subjective data. She should use accurate measurements for data, correct spelling and accepted abbreviations and symbols.
准确。信息必须准确。护士应该清晰的将主观信息与客观信息分开。测量数据时应当使用精确的测量方法，并注意拼写正确，使用公认的简写词汇和符号。
2. Conciseness. The nurse should provide accurate essential information in a short, well-written report or note.
简洁。护士应当简洁清晰地记录准确必要的信息。
3. Thoroughness. Even a short record or report must contain complete information about a patient.
全面。虽然记录要简单，但是内容必须包括病人的完整信息。
4. Currentness. If you do not record or report in time, you may omit something important and patients may not receive the needed care.
及时。如果你不能及时记录或汇报，你可能会忽略掉什么重要的事情，这样病人可能就不能接受必要的治疗。
5. Organization. The nurse should keep all information in a logical format or order. Information should be kept in the order in which it occured. Thus the doctor can better understand it.
有条理。护士应当将病人所有的信息有逻辑、有条理的记录下来。信息的记录应与事件发生事件书序保持一致。这样医生理解起来就会更容易一些。
6. Confidentiality. Information about a patient should only be read by authorized persons. The law protects information about a patient that is gathered by examination, observation, conversation or treatment. It is a nurse's legal duty to keep information about a patient's illness and treatment in secret. Only when staff members are directly involved in a patient's case can they read the patient's record.
保密。关于患者的信息只能由指定人员查看。 通过检测、观察、询问及治疗收集到的病人的信息受法律保护。对患者病情和治疗情况保密是法律规定的护理人员的职责。只有直接涉及病人治疗的工作人员才可以查看病历。
译文属可可原创，仅供学习和交流使用，未经允许不得转载
