[The evolution of nursing record-keeping]

Abstract

Nursing record-keeping forms an integral part of the provision of care. It helps to assure its traceability and monitoring. It also contributes to the circulation of information among the different players involved in the patient's treatment, thereby helping to assure the quality and safety of care. For nurses, whose professional history has its roots in a culture of oral communication, record-keeping represents the affirmation of a real nursing way of thinking.

Keywords: diagnostic infirmier; dossier patient; nursing diagnosis; patient records; rôle propre infirmier; scope of nursing practice; targeted handovers; transmission ciblée; writing; écrit.