vårddokumentationspraxis

vårddokumentation refers to the systematic recording of information related to a patient's care. This documentation serves as a crucial communication tool among healthcare professionals involved in a patient's treatment, ensuring continuity and coordination of care. It includes details about the patient's medical history, symptoms, diagnoses, planned treatments, interventions performed, and the patient's response to care. The process also encompasses observations made by nurses, physicians, and other healthcare providers.

The primary purpose of vårddokumentation is to provide a comprehensive and accurate account of a patient's health status and the care they have received. This record is essential for legal and ethical reasons, serving as evidence of the care provided and decisions made. Furthermore, it plays a vital role in quality improvement initiatives, research, and education within the healthcare sector. Effective vårddokumentation helps to prevent medical errors by ensuring all team members are aware of the patient's current situation and treatment plan. It also facilitates the assessment of treatment effectiveness and supports evidence-based practice.