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Nursing documentation and recording systems of nursing care

Documentation is the written and legal recording of the interventions that concern the patient and it includes a sequence of processes. Documentation is established with the personal record of the patient, which constitutes a base of information on the situation of his health. The importance of nursing documentation is neuralgic, provided that without it, there cannot be a complete qualitative nursing intervention and not even an effective care for the patient. In the purposes of nursing documentation are included the research on a more effective care of the already detected problems, the programming of care through the organization and modification of the plan on patient’s care and the more direct communication between the professionals of the health system, who collaborate on the patient’s care. The methods of documentation are multiple and among the most basic ones are the method directed towards the source or the problem, the system problem-intervention-evaluation, the focused registration, the focusing diagram, the registration by exception, the electronic files and the home documentation

Author(s): Papathanasiou Ioanna

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