Importance And Implementation Of Nursing Documentation: Review Study

Abstract

This study was conducted to review the literature about nursing documentation. We presented the importance and implementation of nursing documentation. The importance of this topic has been realized here, in Jordan, and the Ministry of Health has recently started application of electronic documentation systems. Nursing documentation can be either paper based or electronic based documentation. Paper based documentation has been described not meet the required standards. We argued the standards of nursing documentation that should be met including completeness, clearing, and concision.

Knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia, 2018

“…Even though both paper based and electronic based nursing documentation have various principles including objectivity, speci icity, clearing and consistency, comprehensive, respecting con identiality and factuality, but nurses' inadequate attitude and knowledge to document nursing care by using these principles makes nursing records usually of low quality [6].…”

THE RELATIONSHIP BETWEEN ATTITUDE AND SUPERVISION WITH NURSING DOCUMENTATION COMPLETION IN EMERGENCY DEPARTMENT OF Dr. KARIADI GENERAL HOSPITAL SEMARANG

“…Dokumentasi keperawatan merupakan komponen penting dalam pelayanan pasien secara keseluruhan disamping untuk memenuhi standar akreditasi rumah sakit. Dokumentasi keperawatan digunakan sebagai panduan utama dalam upaya peningkatan pelayanan keperawatan (Alkouri et al, 2015). Dokumentasi keperawatan menjadi instrumen penting untuk menjamin pelayanan kepada pasien dapat dilakukan secara berkesinambungan (Wahab & Elsayed, 2014).…”

Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

“…Nurses have to complete the documentation after delivery of nursing care. Documentation is a form of nursing professionalism and communication tool to healthcare professionals on the patient's condition (1). Documentation will provide an accurate overview of clients, what happened and when it happened.…”