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 …

Accuracy of nursing diagnoses: knowledge, knowledge sources, reasoning skills and the use of Big Data in nursing documentation. An overview of studies of the Research Group in Nursing Diagnostics, Hanze University of Applied Sciences. Dutch and German perspectives on Nursing Diagnosis in Education and …

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