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 …

BACKGROUND: One-third of all medication errors causing harm to hospitalized patients occur in the medication preparation and administration phase, which is predominantly a nursing activity. To monitor, evaluate and improve the quality and safety of this process, evidence-based quality indicators can …

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 …

A pilot study to electronic healthcare documentationDeveloping an international nursing documentation auditinstrument: expert consensus study

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 …

The development of an international nursing documentation standard: the nursing perspective