Polish anaesthesiology nursing documentation: a complex, multi-faceted nursing practice in the context of evidence-based professional practice

Abstract

Abstract Introduction. Research demonstrates that nursing documentation is a condition for the continuity of patient care and for their safety. The objective of the article is to present the existing knowledge on anaesthesiology nursing documentation and to specify its essential elements. Material and methods. A literature review was performed with a systematic literature search. The content of the included studies was analysed in terms of its content and relevance. The materials was gathered through electronic database search. Results. It was found that the key elements of the documentation-related practice of anaesthesiology nurses were as follows: the record-keeping tool should be adjusted to the clinical practice, the documentation for nurses should take into consideration the patient safety aspect and protect nurses from legal consequences; also, the documentation should comply with the current legal regulations and be regularly updated. Conclusions. Anaesthesiology nurses who keep their documentation contribute to improving the safety of patients and themselves. With observations and taking notes on all performed interventions, it is possible to prevent errors and track changes in the patient’s condition reflected in their medical record.