The nurse and her documentation

This publication is the only one on the market that provides up-to-date information on the issue of recording in nursing records by nurses or other health care professionals. It explains in a clear, understandable and readable way how important documentation is for the work of a nurse. Correctness of records in patient documentation, compliance with the instructions for completion, the wording of the record, adequate and appropriate information, this is just a short list of requirements, that recording in the nursing record entails. Since April 2007, the patient or his/her authorised representative has been able not only to consult the documentation, but also to use parts of it for other legal actions. For many health professionals, documentation in nursing is still something that distracts the nurse from the patient, delays her and complicates her work. It should be noted that the documentation kept by the nursing staff is the only evidence in the event that the nurse is called to legal accountability, even if she has not erred in her work. The way the documentation is kept is a calling card of the nurses themselves, their supervisors and the workplace where the nurses work.