Friday, July 24, 2009

Records

Nurses keep accurate records of all care and observations for many purposes. The patient's record is how the different members of the health care team communicate with each other. The chart is a legal document that serves as evidence of care provided. Since the maintenance of records is a legal responsibility, the charts have to meet certain standards, e.g. records must be permanent, accurate, complete, and kept for years after the care was given.