Effectively replaces the traditional "delivery", where the ' nurses at shift end, summarizing a large agenda of the conditions of the users, the interventions performed on them, and any other event worthy of note.
A nursing paper diary can be composed of pages numbered in sequence with the usual name, first name and identification number (or date of birth), and even simple layout lines, by providing more in sequence to score the date, time, comments and acronym of ' nurses compiler.
Even in this case will indicate the most significant changes in the conditions of the user, the objective and subjective data, and all the possible problems that may affect the welfare plan of care . It is not necessary to bring back to diary operations and activities that are performed routinely, such as: administration of therapy to time, blood tests or X-rays.
Instead should be reported: drugs administered 'as needed', x-rays or tests performed outside of the routine, such as investigations of falls or malaise. Avoid writing things that are absolutely useless, typical of the old "delivery".
If you pass the afternoon reading a book, you do not need that ' nurses write in his diary: "Still Afternoon."