Documentation of the nursing process

There are many different systems of nursing documentation in use in a variety of settings. Many of these records are of limited use. Effective documentation is an essential component of the nursing process.

Documentation is important for a number of reasons. Some of these are listed below:

• to provide a valuable record about the patient and for use with the patient

• to provide a comprehensive and dynamic information set about a person's needs, the objectives of care, the care to be given, the progress being made and the outcomes of care

• as a tool to safeguard the continuity of care

• to facilitate the transfer of responsibility for a patient's care, for example, between different wards or hospitals

• as a chronological review of care and its outcomes

• as a basis for evaluation of the efficacy of different nursing interventions

• to provide an educational tool^A

• to provide reliable information for medico-legal examination^B

• to provide reliable data which may be used in nursing research to contribute to the body of nursing knowledge^C

• because there is increasingly a professional expectation and requirement of nurses^D to keep accurate and reliable written records

• because nursing is concerned with^E caring for the whole person for 24 hours a day, our records may include important information for other health care workers involved in a patient's care.

To use the nursing process successfully, a documentation system needs to be developed which reflects both the thought process and the requirements of the particular care setting. The day-to-day documentation of care contributes to the continuity and evaluation of care.

Notes:

a to provide an educational tool — зд.: для использования при обучении (медсестер)

в medico-legal examination — судебно-медицинская экспертиза

с to contribute to the body of nursing knowledge — способствовать накоплению знаний о сестринском деле

D there is increasingly a professional expectation and requirement of nurses... — постоянно возрастают требования к сестрам (в отношении)...

е nursing is concerned with — зд.: сестринский уход направлен на...

From the history of nursing in the usa

Less than a decade after Nightingale served in the Crimea, war erupted in the United States. Following Nightingale's example, women volunteered their services to nurse the sick and wounded soldiers of both sides of the conflict. During the Civil War^A (1861-1865) more than 5000 women served as nurses in one capacity or another. Many of these women had heard or read of Nightingale's activities and reforms during the Crimean War and offered their services to do the same in America. The nurses of the Civil War contributed to sanitary reforms, nutrition support, and patient advocacy^B just as Nightingale had done less then a decade before.

American nursing has developed over the last 130 years in response to social change. After the Civil War, Americans realized that they needed trained nurses to care for patients in the home or hospital. The first three schools of nursing were established in 1873, modeled on Nightingale's plan of economic independence, a matron in charge of the training school^C and experience in the clinical area. However, these schools were unable to sustain themselves financially and soon fell under the control of the hospitals that provided the training experiences for the students.

As the number of hospitals expanded in the last two decades of the nineteenth century, so did the number of nurse training programs in the U.S. Training was difficult with long hours of clinical service and only a few classes that were taught by physicians. Students provided all the nursing care for patients in the hospital and were often cheated of any class time to learn^D about diseases, treatments, or procedures. This caused grave concern to nursing leaders.

Notes:

^A the Civil War (1861-1865) — Гражданская война в США между буржуазным Севером и рабовладельческим Югом. Победу одержали Северные штаты

^в patient advocacy — зд.: защита пациента

^с matron in charge of the training school — зд.: старшая опытная сестра во главе школы

^D were often cheated of any class time to learn.. .—зд.: часто не хватало времени заниматься в учебных аудиториях изучением...