Nursing Documentation in Patient Records

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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 evaluaton of the outcomes of educational programmes in nursing documentation.

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