Nursing Documentation in Patient Records

Abstract

The correct documentation of nursing care is a very important prerequisite for safe care. An extensive survey (n = 380 records), was conducted, using the NoGa protocol for a review of the nurses' documentation. The documentation revealed considerable deficiencies in most of the wards, and the nursing history, status and planned interventions were inadequate in two-thirds of the records. Furthermore, the nursing diagnosis, goals and discharge notes were especially poorly documented. The NoGa protocol was easy to use as an audit tool, useful for screening the nurses' documentation and useful for evaluation of the outcomes of educational programmes in nursing documentation.

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