Professional Documents
Culture Documents
NIM : P1337420618039
Nursing documentation is any written or electronic record that describes the nursing services
provided to clients and can be used as evidence for authorized personnel. The development of
information and communication technology has influenced the activity of managing data and
information in the field of nursing, which affects the development of nursing documentation.
Nursing documentation which from the beginning is a paper-based recording can be developed into
electronic based with the support of information technology and computerized systems. This
information technology-based nursing documentation provides benefits for nurses in terms of
shorter documentation time, data readability and ease of access compared to paper-based
documentation. The development of information technology-based nursing documentation must
still pay attention to the principles of confidentiality of client data, comprehensive, accurate, timely,
and clearly identify care providers so that there is a need for clear policies and guidelines for nurses
in running this system.
NIM : P1337420618039