patient documentation

What are the Legal Aspects of Patient Documentation?

Nurses must be aware of the legal requirements for patient documentation. These include:
Confidentiality: Ensuring that patient information is kept private and only shared with authorized personnel.
Consent: Documenting that patients have given informed consent for treatments and procedures.
Compliance: Following hospital policies and national regulations on patient documentation.
Record Retention: Keeping records for the legally required period.

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