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Varna Medical Forum

NURSING DOCUMENTATION - AN ESSENTIAL FACTOR FOR QUALITY MEDICAL CARE

D. Hristova, V. Tsvetkova

Abstract


The objective of the present study is to examine the opinion of the nursing care specialists working in a Clinic of Internal Medicine at St. Marina University Hospital of Varna about the necessity of introduction and final supplying of nursing documentation. Its separation from the physician`s documentation improves the quality of nursing care. The following items are shaped as nursing documentations: nursing processes, nursing diagnoses, nursing service record`, and nursing care plan`. All these elements oblige the nurse to optimize and improve her everyday activities, to improve the quality of nursing care and thus it becomes her professional duty. The results from the analysis of literature sources and documents as well as of an inquiry method are presented. The study covers the period between June and July, 2012. The results from the questionnaire demonstrate the necessity of introduction and final supplying of nursing documentation.




Keywords

nursing documentation, nursing process, nursing diagnosis, nursing service record, nursing care plan, inquiry


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