Nursing Documents and Documentation for Patients with Heart Diseases; Could Be Made Easier

Abstract

The review article on documents and documentation for heart disease patients was conceived due to the rising prevalence of heart disease among non-communicable diseases. It highlights the need for quality nursing care through effective assessment, planning, implementation, and evaluation. Proper communication among healthcare providers, facilitated by standardized documentation, is essential for documenting patient history and care effectively. The objectives aim to expose many documents for use in the care of cardiac patients, to describe standardized documents used in the care of cardiac patients, and explore difficulties faced with accurate documentation. Information has been sourced from websites, text books, journals, and institutions of health. Results show that Standardized documents ensure that all relevant information is consistently captured, thus reducing the risk of errors and omissions. These documents include, nursing assessment sheets, intake and output charts, nursing care plans, weight monitoring sheets, discharge summaries/ reports, flow sheets, patient’s progress notes, heparin administration form, digitalis/digoxin monitoring charts. It has also been revealed that algorithm sheets for vital signs, weight monitoring sheets, and flow sheets for laboratory results are important. Nursing documentation is shown to be a critical component of patient care, particularly for patients with heart diseases. The recommendations are, that continuous professional training be focused on identifying the best practices for implementing standardized documents for documentation in various healthcare settings, with a particular focus on the care of patients with heart diseases.