RECORD OF INTENSIVE CARE UNIT
Introduction Every ICU keeps some kinds of records. The clinical record is a brief account of the personal and medical history of the patient, results of diagnostic test, findings of medical examination, treatment and nursing care, daily progress notes and advice on discharge. Documentation in the ICU is carried out for a number of reasons. It ensures continuity of care and provides up-to-date patient status. It fulfills hospital policies which furnish the legal aspects of 'duty of care'. The intensive care nurse has to be highly skilled today due to technological advances and complex care of the critically ill patients. Also the documentation and care required are complex and time consuming. Principles of Record Writing Since the clinical record is a legal document, it is essential that they should be written clearly, accurately, appropriately and legibly. All entries should be signed by the individual who writes them. Care to be taken, not to make any errors on the reco...