CONCEPTUAL FRAMEWORK FOR ELECTRONIC NURSING RECORD

Abstract

Nurses are healthcare professionals with a clearly defined job description in most countries worldwide. The fact is that over the years, the essence of their functions has changed dynamically in parallel with the evolving healthcare systems and the healthcare needs of modern societies. Several political, socio economic, and cultural factors influence the nursing profession. In Bulgaria, one of the problems in modern nursing is the outdated nature of these functions and the lack of symbols related to the profession's autonomy, one of which is nursing documentation. The Regulation No. H 5 of October 17, 2025, adopted recently by the Ministry of Health, for the approval of the medical standard "Healthcare," marks the beginning of significant guidelines for Bulgarian nursing, affirming the profession's status and emphasizing its importance and role in healthcare systems. On the one hand, the standard is the result of a long term dialogue between professional organizations, universities, medical institutions, and the government. On the other hand, the relevant requirements are set for medical institutions to comply with European directives and to guarantee the quality of healthcare. Thirdly, although not in importance, the standard requires the development of new, uniform protocols, technical sheets, and algorithms to standardize the didactic and clinical work of all interested structures. An important aspect of these standards is the patient's healthcare record, which will be prepared in the appropriate version, depending on the type of healthcare specialist (nurse, midwife, physician assistant, etc.). Up to now, a limited number of institutions in Bulgaria use the term "nursing record", and it has remained in the sphere of hypotheses and plans for improving nursing theory and practice. The latter is evidenced by numerous sources in the scientific literature, linking the presence of a nursing record to increased care efficiency and quality. At the same time, the development of information technologies and the introduction of the National Health Information System (NHIS) create a prerequisite for the electronic nursing record from the very beginning. Regardless of the carrier of its functionality, timely and reliable framing of its content is necessary, consistent with European standards, Bulgarian legislation, and the specifics of healthcare. The possibility of framing the record is provided through an international project, Contract No. BG RRP 2.004 0007 С01/3.4.16 "Digitalization of nursing care through the implementation of an electronic nursing record" and the international cooperation that arose in its course. This report aims to outline the content of the nursing record, regardless of the carrier, and in accordance with the Medical Standard "Health Care".