What is important in documentation?

What is important in documentation?

Above all, it is important that the documentation remains useful. So that important medical information is recorded in a central location. In this way, everyone involved in the care knows, for example, what medication has been taken. So that changes are noticed and can be correctly assessed.

What is documented in nursing?

A comprehensive nursing documentation should consist of the following elements: Patient summary sheet. Nursing anamnesis. Biography sheet. Collection of medical orders or therapy measures. Medication plan. Nursing plan

Why does it have to be documented?

document. The documentation makes it easier for you to record measures, those responsible and the deadlines for the implementation of the occupational safety measures in a comprehensible manner. It helps to inform employees about existing hazards and to instruct them in safe and healthy behavior.


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