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Keywords:

  • Nursing diagnosis;
  • nursing interventions;
  • standardized nursing language;
  • nursing knowledge;
  • record audit

PURPOSE.  To describe how nursing specialty knowledge is demonstrated in nursing records by use of standardized nursing languages.

METHODS.  A cross-sectional review of nursing records (N = 265) in four specialties.

FINDINGS.  The most common nursing diagnoses represented basic human needs of patients across specialties. The nursing diagnoses and related interventions represented specific knowledge in each specialty. Sixty-three nursing diagnoses (nine appeared in four specialties) and 168 nursing interventions were used (24 appeared in four specialties).

CONCLUSIONS.  Findings suggest that standardized nursing languages are capable of distinguishing between specialties. Further studies with large data sets are needed to explore the relationships between nursing diagnoses and nursing interventions in order to make explicit the knowledge that nurses use in their nursing practice.

PRACTICE IMPLICATIONS.  Nursing data in clinical practice must be stored and retrievable to support clinical decision making, advance nursing knowledge, and the unique perspective of nursing.