DOCUMENTATION IN NURSING PRACTICE AS A TOOL OF PROFESSIONAL SAFETY: MANAGERIAL AND ORGANIZATIONAL PRINCIPLES IN THE CONTEXT OF HEALTHCARE REFORM

Abstract

Introduction. The reform of the healthcare system in Ukraine, accompanied by the autonomization of institutions, increasing legal awareness of patients, and digitalization of the industry, imposes new requirements on the quality of nursing documentation. It is no longer just a recording form but is becoming a key tool for the professional safety of nursing staff. The lack of unified documentation standards and insufficient control by management significantly increase the professional and legal risks for nurses.

The aim of the study – to substantiate the organizational and managerial principles for ensuring the quality of nursing documentation in healthcare facilities, to determine the role of managers at various levels in forming a documentation culture, and to outline mechanisms for minimizing professional risks in the context of healthcare system reform in Ukraine.

The main part. Based on an analysis of scientific publications, regulatory legal acts, and the results of internal audits, the article establishes that quality documentation serves as a tool for the professional protection of nurses, an indicator of the effectiveness of nursing service management, and a guarantee of continuity of care. Typical deficiencies in documentation organization were identified at the facility level, nursing service managers’ level, and the nurses’ level. A model for nursing documentation quality management is proposed, which includes six interrelated components: standardization, training, internal audit, feedback, staff motivation, and integration of documentation into the work process. Special attention is paid to the role of managers at all levels — from the chief nurse to the facility administration — in implementing a culture of quality documentation. Practical recommendations for various categories of personnel and “10 golden rules of documentation” for daily practice have been developed, based on both domestic and international research. The prospects and challenges of digitalizing nursing documentation are considered.

Conclusions. Ensuring the quality of nursing documentation is a complex managerial task that requires systematic participation of managers at all levels. Implementation of the proposed organizational mechanisms will increase the level of professional safety of nurses, reduce legal risks, and improve the quality of medical care. In the context of digital transformation, the rational integration of electronic documentation systems into the work process and continuous staff training become particularly important.