Nursing record

That portion of the medical record which is the responsibility of the nurse. It contains the nursing care plan, nursing orders, and “nurse’s notes” regarding the patient’s response. It provides a sequential record of all nursing activities on behalf of the patient as well as accountability and validation of orders (physician and nurse) being carried out. When the nurse maintains a similar record for a person who is not ill, the person is referred to as a “client.”


 


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