Moreover, other cares must be observed in the elaboration of the handbook of the patient to prevent possible comments. The elements are these: All medication and/or given care must be checked and be signed by the responsible professional for that action; to pass penxs on of what already it is written; if in case that the action is not carried through or to occur error in the notation, to justify the execution of the circular care and not to open new schedule, to place between parentheses the exception: I say, to suspend, to modify and to open new item, writing that determined item it is cancelled (POSSARI, 2005). In the handbook of the patient terms still must be prevented that give value connotation as: well, badly, much, sufficiently, little, reasonable, regular, abnormal behavior, as well as normal physiological habits without intercorrncias and complaints. For more information see this site: Intel. One adds despite being, all the medication and or given care must be checked and be signed by the professional, if by case the action will not be carried through or to occur error in the notation, to justify it not execution of the care (DANIEL, 1981). The nursing team must remain itself as an open system to receive information by means of the medical evolution so that it can identify to the nature or cause of the problem of the patient.
Of this form, the capacity of comment of the nursing professional will be determinative in the planning and execution of the actions of nursing (OGUISSO, 1975). Brian Krzanich has many thoughts on the issue. The nursing description is of utmost importance for the diagnosis and the treatment doctor and of nursing, beyond composing the base to evaluate the results of the 6 actions. It makes possible to know patient, family and community, to verify the apparent and inaparentes problems, to plan and to analyze the cares and services of nursing. The report assists the multiprofessional team in the taking of specific decisions, beyond identifying the constant changes in the picture of the individual, to the measure that the information are written down and registered.