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Keywords:

  • nursing assessment;
  • nursing diagnoses;
  • nursing documentation;
  • nursing interventions;
  • nursing outcomes;
  • nursing process

Aims and objectives.  To describe the change in documentation of the nursing process in all inpatient wards in a 900-bed university hospital. Major research question was what are the differences between before and after implementation of documentation policy related to the steps of the nursing process?

Background.  Implementation of standardized languages has been shown to be difficult to accomplish in clinical practice. Patients are the source of data and their conditions, responses and well-being should be reflected in the nursing record. As such, nursing documentation can create the premises for the development of new knowledge in nursing and the improvement of nursing performance and can provide data and information necessary for nursing researchers to evaluate the quality of interventions and participate in the formulation of healthcare policy. This study is part of longitudinal project to prepare nurses for electronic documentation within the interdisciplinary health record and to improve documentation of nursing using standardized languages.

Design and method.  A cross-sectional study design was used: a pretest (n = 355 nursing records) for baseline status of nursing documentation, an intervention and a post-test (n = 349 nursing records) to obtain data on nursing documentation. The year-long intervention comprised planned work in groups, and educational and supporting efforts.

Results.  A statistically significant improvement was found in the use of Functional Health Patterns for documentation of nursing assessment, NANDA for nursing diagnoses and Nursing Interventions Classification for nursing interventions in documentation of daily nursing care for inpatients.

Conclusion.  At all organizational levels intervention aimed at putting policy regarding documentation into clinical practice considerably improved daily use of standardized nursing languages.

Relevance to clinical practice.  Nurses need to use standardized language to document patient care data in the electronic health record and to demonstrate contributions to nursing care.