Abstract

To ensure better-quality documentation of patients’ nursing care needs and prepare for DRGbased funding, many hospitals have started implementing the NANDA-I classification for nursing diagnoses. The Burgerspital Solothurn (soH AG) started this implementation process in 2001, followed by development of an electronic nursing documentation system containing internationally recognised terminologies and a standardised infrastructure for data management. Not only have evaluations shown enhanced quality of nursing documentation; studies have also revealed that the implementation of NANDA-I diagnoses enhances assessment of nursing care needs. Moreover, implementation of standardised nursing diagnoses leads to more effective nursing interventions and significantly better patient outcomes. This article describes a nursing documentation system that is now commercially available.

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