PURPOSE. To investigate the effects on the quality of nursing diagnostic statements in patient records after education in the nursing process and implementation of new forms for recording.
METHODS. Quasi-experimental design. Randomly selected patient records reviewed before and after intervention from one experimental unit (n = 70) and three control units (n = 70). A scale with 14 characteristics pertaining to nursing diagnoses was developed and used together with the instrument (CAT-CH-ING) for record review.
FINDINGS. Quality of nursing diagnostic statements improved in the experimental unit, whereas no improvement was found in the control units. Serious flaws in the use of the etiology component were found.
CONCLUSION. Nurses must be more concerned with the accuracy and quality of the nursing diagnoses and the etiology component needs to be given special attention.
PRACTICE IMPLICATIONS. Education of RNs in nursing diagnostic statements and peer review using standardized evaluation instruments can be means to further enhance RNs’ documentation practice.
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