Federal Advice
this the way of that if it makes use for control and evaluation of the given assistance (DUARTE, 1976). The notation, as well as the evolution, is instruments of great value, meaning and importance in the assistance of nursing and its continuity, becoming both indispensable ones in the application of the nursing process (DANIEL, 1981). The 7 purposes of the nursing notations as Daniel (1981 p.132) are: to tell in writing to the comments of the patient or customer; to contribute with information to become medical diagnosis and of nursing, as well as the planning of the plan of cares that will be used; to serve of element for research; to supply given auditorship in nursing; to serve for evaluation of the given cares of nursing (how much the quality and continuity); to serve as source of continuity of the treatment of the patient, protecting the efforts expended for the medical team and of nursing. Click Ben Horowitz to learn more. The register of all the comments made in relation to the patient with explanation of the results of the treatment, given cares, given evolution of the signals and symptoms, orientaes, feeding, monitorizaes, dressings, amongst others. The doctor signs the lapsings and the nurse or technician before requesting the lapsing it necessary pharmacy to make the order of materials and to exclude the unnecessary ones.
Therefore, the fulfilling of the handbook of the patient is obligation and intransfervel responsibility of the health team, with exception of the education hospitals, in which the pupils of medicine, nursing and to other make it professions under supervision, correction responsibility of doctors, nurses and other professionals. (POSSARI, 2005). Ethical and legal landmarks on the Handbook of the Patient art. 3 of Resolution 272 of the Federal Advice of Nursing (COFEN, 2002), makes use that ' ' systematization of the nursing assistance (SAE) will have formal to be registered in the handbook of the patient/using customer/, having to be composed for: Physical description of nursing, examinations; nursing disgnostic; lapsing of the nursing assistance; evolution of the nursing assistance; report of enfermagem' '.