Documentation In The Nursing Process

Since the time of Florence Nightingale (1859) nurses have viewed patient documentation as a pivotal aspect of nursing care. Many of the fundamental concepts set forth by Nightingale are still strong foundations for nursing practice despite modifications being made to meet the demands of the 21st century health care. (Clements and Avrill, 2006). Furthermore , the 1980s brought about a new proposition in nursing care namely the nursing process which redefined the role of the nurse. (Muller- Staub et al, 2006).Evaluation is classified as the final stage of the nursing process. The nursing process can be seen as the systematic, humanistic and rational method of establishing and delivering nursing care. It occurs in stages namely assessment, planning,

Documentation is a communication tool for the handover of information stored in records between other members of the Multi-disciplinary team. (Urquhart et al, 2009). Nursing documentation is a record of nursing care that is scheduled and given to the individual patients by qualified staff nurses and other caregivers under the direction of a qualified nurse. It has continuously developed due to the increasing research on the nursing process and has been an area of concern since the early days Of Nightingale. ( Urquhart et al, 2009). Nursing documentation encourage many aspects of nursing care. Voutilainen et al, 2004 believes that quality nursing documentation promotes structured, dependable and effective communication between caregivers and will facilitate continuity and individuality of care and safety towards patients. One believes documentation is a useful tool in addressing what happens in the nursing process and what decision making is based on presenting information from admission, nursing diagnosis, interventions and the evaluation process resulting in the outcome. Delaney et al, 1992 firmly believes that exact nursing documentation allows nurses to evaluate nursing outcomes as a logic result of nursing diagnosis and

According to Praikoff et al 2005, research reveals that nurses prefer to be informed by colleagues rather than using databases or the internet and most nursing professionals rely on previous education they received during their nursing training. In fact during their research they also found that even when nurses are exposed to the most recent knowledge either through journal articles or nursing databases they rarely ever apply it to practice. Yates(2015) arises the argument that for healthcare professionals to keep up to date with evidence based practice is very time consuming and places extra demands on them resulting in them feeling overwhelmed which can have a negative impact on patient outcomes. Mullen and Streinor, 2004 also argue that individuals that utilize evidence based practice will have the belief that their results will be superior to those who don’t demonstrate best practice. One believes that this can