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What are the key factors to remember about recording information in a plan of care? |
any body? The key factors from my experience are 1.How the person feels 2. How the environment affects the person being cared for be it in hospital or in the community 3. Accuracy -- always document properly what you observe about the person being cared for 4. If it is nor written down, it never happened 5. Who was present at the point of care ie doctors, nurses etc. 6. Document outcomes of care. |
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