Table 1 Comprehensiveness scores according to CIND^a and corresponding descriptions of the PCC^b-categories in the nursing documentation

Score of 1

The problem is described, or interventions planned or implemented

[1] PCC-ND^c or [2] PCC-NIV^d is present in NCP^e, or [3] statement that the PCC-NIV is completed

[1] “Needs assistance in managing own behavior” or [2] “One-on-one follow-up when signs of agitation” or [3] “The resident has been agitated today. They received one-on-one follow-up.”

Score of 2

The problem is described, and interventions planned or implemented

[1] PCC-ND and [2] PCC-NIV is present in NCP, or [3] statement that the PCC-NIV is completed

[1] “Needs assistance in managing own behavior” and [2] “One-on-one follow-up when signs of agitation” or [3] “The resident has been agitated today. They received one-on-one follow-up.”

Score of 3

The problem is described, and intervention planned or implemented, and resident outcome is recorded

[1] PCC-ND and [2] PCC-NIV are present in NCP, or [3] statement that PCC-NIV is completed and [4] PCC-NO^f is recorded

[1] ‘Needs assistance in managing own behavior” and [2] “One-on-one follow-up when signs of agitation” or [3] “The resident has been agitated today. They received one-on-one follow-up and [4] without any effect.”

Score of 4

The problem is described, and intervention planned and implemented, and nursing outcome is recorded

[1] PCC-ND and [2] PCC-NIV are present and statement [3] that the PCC-NIV is completed and [3] PCC-NO is recorded

[1] “Needs assistance in managing own behavior” and [2] “One-on-one follow-up when signs of agitation” and [3]“The resident has been agitated today. They received one-on-one follow-up and [4] without any effect.”

Score of 5

All aspects of the nursing process are recorded, including nursing history, diagnosis, goals, and discharge notes. There is an adequate description of the problem. The recording is of relevance to nursing

[1] PCC-ND described adequately with present [2] PCC-NG^g and [3] PCC-NIV is present. Statement that the [4] PCC-NIV is completed [5], PCC-NO is recorded, an evaluation of the resident’s experience of completed PCC-NIV is recorded

[1] “Needs assistance in managing own behavior. The resident has no insight into own health condition. Reacts negatively with anger to changes made to surroundings. Has reacted in a hostile manner toward other residents, relatives and staff.” [2] “Resident feels seen and understood.” [3] “One-on-one follow-up when signs of agitation occur.” [4] “The resident has been agitated today. They received one-on-one follow-up without any effect. [5] They were in despair and started crying when expressing how much they missed their partner.”