The relationship between nursing and medical records in developing health services

Abstract

Medical records are fundamental tools in healthcare, playing a crucial role in the development of nursing services. They provide comprehensive documentation of patient histories, diagnoses, treatments, and outcomes, enabling nurses to deliver high-quality, patient-centered care. This systematic review examines the role of medical records in enhancing nursing practices, focusing on their impact on care planning, clinical decision-making, and patient safety. The review also explores the integration of electronic medical records (EMRs), highlighting their benefits in improving data accuracy, accessibility, and care coordination. While EMRs have revolutionized nursing practices, challenges such as inadequate training, system usability issues, and data security concerns persist. Addressing these challenges and leveraging emerging technologies, such as predictive analytics and artificial intelligence, offer opportunities to maximize the potential of medical records in advancing nursing services. The findings underscore the importance of medical records as essential resources for fostering evidence-based practices, ensuring continuity of care, and driving the professional development of nurses, ultimately improving healthcare outcomes.