Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named …

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 …

Background: Nursing documentation could improve the quality of nursing care by being an important source of information about patients' needs and nursing interventions. Standardized terminologies (e.g. NANDA International and the Omaha System) are expected to enhance the accuracy of nursing documentation. …

Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study …

Nursing Platform UMCG Diagnostics and Technology in Modern Nursing Times

AIM: To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. DESIGN: Systematic review of systematic reviews. DATA SOURCES: We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional …