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PURPOSE: 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. SIGNIFICANCE: Obtaining information about nursing practice is critical in times of health care change and reform. CONCLUSIONS: 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. IMPLICATIONS: 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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Iowa Intervaention Project (1997) studied this question.
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