AIM: To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice. BACKGROUND: Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several …

AIM: This paper is a report of a study conducted to describe the accuracy of nursing documentation in patient records in hospitals. Background.  Accurate nursing documentation enables nurses to systematically review the nursing process and to evaluate the quality of care. Assessing nurses' reports in …

AIM: This paper is a report of the development and testing of the psychometric properties of an instrument to measure the accuracy of nursing documentation in general hospitals. BACKGROUND: Little information is available about the accuracy of nursing documentation. None of the existing instruments that …