Nursing Documentation
(การจัดทำเอกสารพยาบาล)
Definition
Nursing Documentation (การจัดทำเอกสารพยาบาล) Hard Skill
The systematic recording and maintenance of accurate, comprehensive, and timely patient care information by nurses to ensure effective communication and continuity of care.
Expertise Level
Level 1
Basic
1. Understands the importance of accurate nursing documentation.
2. Can record basic patient information and vital signs correctly.
3. Follows standard formats and guidelines for documentation.
Level 2
Intermediate
1. Accurately documents nursing interventions and patient responses.
2. Ensures documentation supports care planning and decision making.
3. Maintains confidentiality and legal compliance in record keeping.
Level 3
Advanced
1. Synthesizes complex patient data into clear, comprehensive documentation.
2. Leads improvements in documentation practices and training.
3. Utilizes documentation to contribute to quality assurance and patient safety.
