Liječnički vjesnik, Vol. 146 No. 1-2, 2024.
Stručni rad
https://doi.org/10.26800/LV-146-1-2-8
Nursing documentation as important part of the medical documentation
Kristina Hanžek
orcid.org/0000-0001-7358-9387
; Klinika za neurologiju Medicinskog fakulteta Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb
Sažetak
Nursing documentation is part of the patient’s medical documentation and, according to the Nursing Act in the Republic of Croatia, nurses have the obligation and duty to maintain such documentation that records all procedures performed on the patient during a 24-hour period. Documentation is important due to: legal protection (nursing documentation is a document that verifies facts and claims in case of potential legal dispute or conflict), monitoring healthcare costs (it enables tracking costs in relation to effectiveness, is a source of information
for research that can obtain significant results useful for the development of nursing practice, nursing standards, improvement of the quality of health care (documentation is proof of provided health care and nursing interventions), social changes, improvement of communication in the team. Correct and timely nursing documentation with accurate and relevant information about the patient significantly affects successful communication
in the multidisciplinary team due to the availability of nursing records in the hospital information system, as well as other members of the team who are in charge of the patient. One of the most important components of nursing documentation is the permanent monitoring of the patient’s condition, i.e., decursus, in which all changes in the patient during a 24-hour period are documented (symptoms, signs, descriptions of the new state of the patient, possible causes, and additional data that is not stated in the anamnesis). In previous studies deficiencies
have been identified, such as untimeliness in documentation, incorrect data, discontinuity in the documentation of the decursus, unclear instructions. The purpose of this article is to emphasize the importance of nursing documentations a legally regulated document in nursing profession in Croatia and as important part of the overall medical documentation.
Ključne riječi
NURSING RECORDS – legislation and jurisprudence; DOCUMENTATION; HOSPITAL INFORMATION SYSTEMS; ELECTRONIC HEALTH RECORDS; NURSE’S ROLE; QUALITY ASSURANCE, HEALTH CARE; CROATIA
Hrčak ID:
314686
URI
Datum izdavanja:
27.2.2024.
Posjeta: 248 *