Table 1 The criteria and standards of the items of N-Catch, the evidence base and sources of data collection

The nursing process

The nursing record should contain:

Wang, Hailey & Yu [4], Saranto & Kinnunen [1], The Norwegian Board of Health [20]

Nursing documentation in the nursing record

• Assessment on admission

• The patient’s personal details

• Nursing care plan

• Progress and evaluation notes

Standard: 100% of the nursing records should fulfill these criteria

The patient’s personal details should include name, address, date of birth, telephone number, marital status, next of kin, occupation, general practitioner

The Norwegian Board of Health [20]

The personal details file in the patient record

Standard: 100% of the patient records should contain these elements

Assessment

The assessment on admission:

Wang, Hailey & Yu [4], Müller-Staub et al. [11], The Norwegian Board of Health [20]

The admission note in the nursing record

• Quantity: The patient’s health history, the reason for admission and the patient’s health status should be completely documented

• Quality: The language should be correct and concise, and all relevant information should be included

Standard: 100% of the admission notes should fulfill these criteria

Nursing care plan Implementation

The nursing care plan:

Wang, Hailey & Yu [4], Jefferies, Johnson & Griffiths [3], Suhonen, Välimäki & Leino-Kilpi [22], Ehnfors, Ehrenberg & Thorell-Ekstrand [16], The Norwegian Board of Health [20]

The nursing care plan in the nursing record

• Quantity: The nursing care plan should be updated and individualized, and contain nursing diagnoses, nursing outcomes and nursing interventions.

• Nursing diagnoses: Should contain information about the symptoms, consequences and the patients’ resources

• Nursing outcomes: Should be measurable and realistic and describe a desired situation for the patient in the future

• Nursing interventions: Should be specific and linked to nursing diagnoses and nursing outcomes

Standard: 100% of the nursing care plans should fulfill these criteria

Evaluation

Evaluation - progress notes:

Wang, Hailey & Yu [4], Jefferies, Johnson & Griffiths [3], Saranto & Kinnunen [1], Ehnfors, Ehrenberg & Thorell-Ekstand [16], The Norwegian Board of Health [20]

Progress and evaluation notes in the nursing record

• Quantity: Progress reports should be written after each shift

• Quality: Progress reports should assess the patients’ health status according to nursing outcomes. The language should be correct and concise

Standard: 100% of the progress reports should fulfill these criteria

Evaluation

Evaluation - discharge notes:

Wang, Hailey & Yu [4], Saranto & Kinnunen [1], The Norwegian Board of Health [20]

Discharge notes in the nursing record

• Should contain relevant information important to understand the patients’ health status on discharge.

• Should contain evaluation of results.

• The language should be correct and concise.

Standard: 100% of the discharge notes should fulfill these criteria