Table 1 Criteria and standards for nursing documentation in electronic patient records
From: Improving the quality of nursing documentation at a residential care home: a clinical audit
The nursing process | Criteria (N-Catch) | Evidence base | Standard |
|---|---|---|---|
Nursing assessment on admission | The patient’s health history, the reason for admission and the patient’s health status should be completely documented | Wang, Hailey & Yu [9], Norwegian Ministry of Health and Care Services [16] | 100 % of admission notes should fulfill these criteria (N-catch score = 3) |
Nursing diagnoses | Nursing problem, etiology and symptoms should be clearly described. | Wang, Hailey & Yu [9], Müller-Staub et al. [8], Norwegian Ministry of Health and Care Services [16] | 100 % of nursing care plans should fulfill these criteria (N-catch score = 3) |
Aims for nursing care | Aims should relate to nursing diagnosis, be measurable, realistic and describe a desired situation for the patient in the future. | Wang, Hailey & Yu [9], Norwegian Ministry of Health and Care Services [16] | 100 % of nursing care plans should fulfill these criteria (N-catch score = 3) |
Nursing interventions | Nursing interventions should be specific and relate to nursing diagnosis and aims. | Wang, Hailey & Yu [9], Norwegian Ministry of Health and Care Services [16] | 100 % of nursing care plans should fulfill these criteria (N-catch score = 3) |
Evaluation/ progress reports | Evaluations/ progress reports should assess the patients’ health status and relate to nursing diagnoses, aims and nursing interventions. | Jefferies, Johnson &Griffiths [18], Norwegian Ministry of Health and Care Services [16] | 100 % of evaluation reports should fulfill these criteria (N-catch score = 3) |