Introduction: Nursing documentation appropriate standards of nursing language (Standarized Nursing Language), was still a problem in the nursing profession, especially uniformity in using nursing diagnoses and interventions language. Instrument were needed to produce a good quality of nursing diagnosis and intervention’s documentation. The purpose of the research was to develop nursing diagno…
Purpose: This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology. Methods: An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective …