AL NEELAIN NURSING SCIENCE JOURNAL - VOL - 01
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Item Documentation in Nursing(Faculty of Nursing Sciences - Al Neelain University, 2020) Khozima Mohammed Abdala, Egbal Abbashar Algamar AlmkiyHistorical Perspectives: Since the time of Florence Nightingale, nurses have viewed documentation as a very important aspect of their professional practice. Nightingale described the need to document data with an aim of collecting and retrieving information to aid in proper patient management. Previous study, confirmed that whereas the aim of documentation in Nightingale’s time was mainly to communicate implementation of doctors orders. Today’s nursing documentation is applied in all the steps of the Nursing process from assessment to the evaluation. Virginia Henderson, a nurse theorist, promoted the use of documentation when she introduced the idea of using the nursing care plans to communicate nursing care during the 1930’s. However, the nursing documentation was discarded after the patient had been discharged. Since 1970’s, nursing documentation has become more important reflecting the changes in nursing practice, regulatory agency requirements and legal guidelines. Nursing documentation has also evolved as an important mechanism in determining monetary reimbursement of the care provided to clients/patients (1)Over the last few decades, more efforts have been made to advance nursing documentation to increase its usability. One of these initiatives was the development and use of research based standardized nursing terminologies such as the International Classification of Nursing Practice (ICNP) and the International Nursing Diagnoses Classification (NANDA International) Standardized nursing languages provide common definitions of nursing concepts and allow for theory based and comparable nursing data to emerge there for they promote shared understanding and continuity of care and make it possible to use records for research and management purposes The introduction of electronic documentation systems into care practice has led to the transformation of nursing record-keeping. Electronic documentation systems can improve health professionals access to more complete, accurate, legible and up-to-date patient data(2) Background: Documentation is sometimes viewed as burdensome and even as a distraction from patient care.)3) Documentation and record keeping is a vital part of registered nursing practice. The quality and coordination of client care depends on the communication between different health-care providers. (4) Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation is paper-based or electronic(5)