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Keywords:

  • Nursing classification systems;
  • clinical information systems;
  • comparative effectiveness research

Purpose.  Rank and compare the 10 most frequently documented nursing diagnoses, interventions, and patient outcomes using NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification for care of patients with heart failure (HF).

Methods.  A descriptive comparative multisite study of documented care for 302 older adults with HF.

Findings.  There were four common nursing diagnoses, two interventions, and only three common outcomes across three sites.

Conclusions.  This and similar analyses of clinical nursing data can be used by nursing administrators and clinicians to monitor the quality and effectiveness of nursing care.

Implications.  Similar analyses may be used for continuing education, quality improvement, and documentation system refinement. Part 2 will discuss data retrieval and implications for building a multiorganizational data warehouse.