The significance and implementation of nursing process documentation in the endoscopy cabinet

Abstract

Any systematic and high-quality work in any profession is based on well-designed documentation. In the nursing profession, mistakes and omissions are not allowed precisely because their work is focused on the care of persons who represent a particularly vulnerable category, namely users of health services. In order to implement nursing interventions as efficiently and comprehensively as possible, the implementation of the nursing process is important, which requires a well-organized system of documentation, which is available to all members of the nursing team. The nursing process documentation is a standardized documentation that has been developed, modified and improved since the 1950s. Over time, it has been adapted to meet the needs of different health institutions and health services. The documentation of the nursing process is most often applied in health institutions where secondary and tertiary health care is provided, as well as in work with students of academic institutions of the health profession. Documentation of the nursing process in the Republic of Serbia is rarely used in primary health care, and it is also not fully implemented in secondary and tertiary health care institutions. Practical experience confirms that it is most often implemented in departments of internal medicine, while it is rarely used in departments of surgery or radiology, and its implementation is completely omitted in day hospitals and cabinets that are integral parts of these institutions, or in dispensaries of primary health care institutions. Precisely for these reasons, the aim of this paper was to assess the importance and implementation of nursing process documentation in the Endoscopy Cabinet for patients of the Institute of Oncology and Radiology of Serbia.