| 摘要 |
A documentation system that allows adequate control of documentation in addition to an assessment of skills of the professionals involved includes a plurality of notepads, each notepad dedicated to a particular disease process or body system. Each of the notepads has disposed therein a plurality of adhesive-backed labels, each label providing a checklist of assessment steps or an anatomical diagram of a particular body system. The labels are operable to be removed and temporarily placed on the chart of the patient during an acute episode, incident, or accident, or may be permanently placed in the patient's chart to describe adequately the patient's condition. In addition, the anatomy labels are operable to be removed from the notepad and given to the patient to assist the patient in understanding his/her disease process or medical condition. Also included is an optional Charting Reminder Tool form, operable to be placed in the patient's chart for attachment of the labels.
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