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Keywords:

  • documentation;
  • classification;
  • computer/information systems;
  • nursing minimum data set

Purpose: To address issues related to documentation of nursing care and propose a model that illustrates how nursing practice data, collected through the use of standardized languages, are useful to staff nurses, nurse administrators, researchers, and policy makers.

Significance: Obtaining information about nursing practice is critical in times of health care change and reform.

Conclusions: There are three main challenges: the level of detail to document, the inclusion of nursing language in critical paths, and the need for articulation among different nursing classifications.

Implications: With recent advances in nursing classifications, the documentation systems in nursing can now be improved and much of the previous waste and redundancy eliminated.