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Evaluation of nursing process documentation
Author(s) -
Davis Bryn D.,
Billings Jennifer R.,
Ryland Richard K.
Publication year - 1994
Publication title -
journal of advanced nursing
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.948
H-Index - 155
eISSN - 1365-2648
pISSN - 0309-2402
DOI - 10.1111/j.1365-2648.1994.tb01175.x
Subject(s) - documentation , nursing process , nursing , process (computing) , psychological intervention , nursing interventions classification , psychology , service (business) , medicine , medical education , computer science , business , marketing , programming language , operating system
Following the introduction of a nursing process and associated documentation in one hospital, an attempt was made to evaluate the effectiveness of the documentation as a record of the nursing process. Two questionnaires were developed, based on previous research in this field, one for the assessment of the documentation, and the other to assess the attitudes and practices of the ward sisters regarding its implementation. The findings indicated that, generally, the assessment phase of the process was poorly documented and that many psychological and social problems were not addressed as well as others. The interventions were relevant but contained little detail. The evaluation section was fair but updating and re‐assessment where relevant were poor. Some sisters seemed to display a lack of understanding of the principles or the practice of the process, despite in‐service education. Lessons to be learnt from the exercise are suggested.