Background The nurses' ability to document patient's status, problems and progress is an
important issue in patients' safety. Nursing terminologies are intended to support nursing …

A range of different language systems for nursing diagnosis, interventions and outcomes are
currently available. Nursing terminologies are intended to support nursing practice but they …

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 …

Background Since the emergence of electronic health records, nursing information is
increasingly being recorded and stored digitally. Several studies have shown that a wide …

Objectives The aim of this study was to develop and validate Detailed Clinical Models
(DCMs) for nursing assessments and interventions. Methods First, we identified the nursing …

Nurses are accountable to apply the nursing process, which is key for patient care: It is a
problem-solving process providing the structure for care plans and documentation. The state …

Purpose The purpose of this study was to describe the extent to which nursing assessment
data was present in the electronic health record and linked to NANDA‐I, NIC, and NOC …

PURPOSE: The purpose of this study was to describe and evaluate whether nurses have
documented patient care in compliance with the national nursing documentation model in …

The article discusses a survey which addresses nurses attitudes and perceptions about
standardized nursing terminologies completed by the authors in the fall of 2011. Topics …

Background The use of standardised terminologies for electronic health records (EHRs) is
important and a sufficient coverage of all aspects of health care is increasingly being …