Working groups for nursing documentation development

Following the support of ProSes to entity working groups to develop/amend existing rulebooks on the form and content of the basic medical documentation, the nursing documentation development process has started. The documentation will be aligned with international standards and directives and tested before it becomes compulsory.

Nursing documentation is an integral part of the patient medical record and nurses’ daily work. It documents planned and given nursing care and therefore is the nurse’ responsibility.

Nurses document their work and patient care outcomes for many reasons: communication with the medical team, legal protection, chronological patient care overview, continuity assurance, accreditation, quality assessment, refunding for the care provided, conducting research, etc.

Documenting is sometimes perceived as an additional burden and even as a distractor from patient care. However, nursing documentation enables demonstration and better apprehension of nurses’ contribution to patient care outcomes and the effectiveness of the overall health system, and therefore can assist in affirmation of the nursing profession.

Clear, accurate and accessible documentation is an essential element of safe, quality and evidence-based health service provision. Accurate and timely nursing documentation is essential for good communication in a multidisciplinary team. Structured and standardized documentation is of special significance for safe and high-quality nursing care provision.