OBJECTIVES Previous studies regarding nursing documentation focused primarily on documentation quality, for instance, in terms of the accuracy of the documentation. The combination between accuracy measurements and the quality and frequencies of outcome variables such as the length of the hospital stay …

PURPOSE: The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs. METHODS: A stratified cross-sectional random-sampling nursing documentation audit …

To evaluate the effect of the educational program "Guided Clinical Reasoning" (GCR) and the introduction of an intelligent electronic nursing documentation system (e-doc) on the quality of the nursing process. Evaluation was conducted at three measurement points and rated with the instrument "Quality …

BACKGROUND: This paper reports a study about the effect of knowledge sources, such as handbooks, an assessment format and a predefined record structure for diagnostic documentation, as well as the influence of knowledge, disposition toward critical thinking and reasoning skills, on the accuracy of nursing …

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 …

Delirium is a serious and frequent psycho-organic disorder in critically ill patients. Reported incidence rates vary to a large extent and there is a paucity of data concerning delirium incidence rates for the different subgroups of intensive care unit (ICU) patients and their short-term health consequences. …

In cases of cognitive decline not due to delirium, the daily observation of cognitive function by nurses has not been standardised in hospital wards specialised in the care of older people. A qualitative study with purposive sampling and semi-structured interviews. Methods. Data were obtained by interviewing …

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 …

The purpose of this study was to determine how knowledge sources, ready knowledge, and disposition toward critical thinking and reasoning skills influence the accuracy of student nurses' diagnoses. A randomized controlled trial was conducted to determine the influence of knowledge sources. We used the …