Abstract

To address issues related to documentation of nursing care and propose a model that illustrates how nursing practice data, collected through the use of standardized languages, are useful to staff nurses, nurse administrators, researchers, and policy makers. Obtaining information about nursing practice is critical in times of health care change and reform. There are three main challenges: the level of detail to document, the inclusion of nursing language in critical paths, and the need for articulation among different nursing classifications. With recent advances in nursing classifications, the documentation systems in nursing can now be improved and much of the previous waste and redundancy eliminated.

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