Documentation in nursing care: literature review

Abstract

Documentation in nursing care in an important part of the whole documentation of a patient. Documentation of nursing care presents the documentation of separate phases of the process of nursing care. Documentation of nursing care has an important impact on the continuation and quality of nursing care, on communication among health team members and can also represent a basis for research work. In order to present a survey of literature, descriptive research method was used. Sources, contents and results of the research were processed to show the above stated facts about the purpose of the documentation of nursing care and in the light of some factors influencing it: information technology, points of view of nurses, ethics of their work and teaching process. The survey of literature revealed that several research studies and documents exist and that nursing care documentation takes on many forms, form written ones to computer assisted. Different classification systems are used. The majority of the mentioned studies have supported the above mentioned presumptions and that nursing care documentation has many positive aspects.