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A patient's record is a written document. It can keep information about a patient's health permanently.
患者的病歷是一份書面文件。里面永久性地記載這患者的健康信息。
If it is well written and organized, the nurse may take care of the patient more effectively.
如果病例內容清晰、有條理，護士能夠更有效地照顧病人。
There are 6 useful points to follow to make sure the quality of reporting.
為確保病歷質量，護士應當遵循六點注意事項。
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.
準確。信息必須準確。護士應該清晰的將主觀信息與客觀信息分開。測量數據時應當使用精確的測量方法，并注意拼寫正確，使用公認的簡寫詞匯和符號。
2. Conciseness. The nurse should provide accurate essential information in a short, well-written report or note.
簡潔。護士應當簡潔清晰地記錄準確必要的信息。
3. Thoroughness. Even a short record or report must contain complete information about a patient.
全面。雖然記錄要簡單，但是內容必須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.
及時。如果你不能及時記錄或匯報，你可能會忽略掉什么重要的事情，這樣病人可能就不能接受必要的治療。
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.
有條理。護士應當將病人所有的信息有邏輯、有條理的記錄下來。信息的記錄應與事件發生事件書序保持一致。這樣醫生理解起來就會更容易一些。
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。關于患者的信息只能由指定人員查看。 通過檢測、觀察、詢問及治療收集到的病人的信息受法律保護。對患者病情和治療情況保密是法律規定的護理人員的職責。只有直接涉及病人治療的工作人員才可以查看病歷。
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