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Metas de Enfermería

Metas de Enfermería

JULIO 2010 N° 6 Volumen 13

Nursing registry: a reflection of care delivery work

Section: Hands on

How to quote

Jiménez Fernández JC, Cerrillo Martín D. Registros de Enfermería: un espejo del trabajo asistencial. Metas de Enferm jul/ago 2010; 13(6): 8-11

Authors

1Juan Carlos Jiménez Fernández2Daniel Cerrillo Martín

Position

1Diplomado en Enfermería. Unidad de Cuidados Intensivos HRT del Hospital Universitario Virgen del Rocío, Sevilla. 2Diplomado en Enfermería.

Contact email: juankigenial@hotmail.com

Abstract

The traditional resistance of nursing professionals to the use of registries has been motivated by two problems: a negative attitude, due to the lack of time, the load entailed by care delivery work, not having made a habit of using registries, and the lack of the appropriate language and inadequacy of documents. Nursing registries can be defined as the documental support that contains all of the information on the nursing activity conducted in relation to a specific person and his or her assessment, treatment received and evolution, and, in addition to serving as a documental registry, it can also be used to benefit the medical centre and staff, as well as to support the defence when faced with legal action. At present, the ever present idea that “the more is registered the better” is being uprooted and replaced by the definition of several different guiding criteria on how to carry out nursing registries. Amongst others, the General Health Care Law is very clear on the right of all patients to have their entire process in written, as well as the Patient Autonomy Law and other legal and deontological regulations.

Keywords:

care; clinical documentation; continuity; legal framework; nursing registryquality

Versión en Español

Título:

Registros de Enfermería: un espejo del trabajo asistencial