Using standardized terminology for nursing documentation

Abstract

The documentation of nursing data is one important part of compiling information about patient care. Information recorded by using standardized and coded terms is needed to facilitate the subsequent use of nursing data. Structured data can be used to describe, compare and support nursing practice, research, education and management. The possibility of narrative text must also be included in documentation. The Finnish Classification of Nursing Interventions (FiCNI)Ensio A. & Saranto K.: The Finnish Classification of Nursing Interventions (FiCNI) based firmly on the Home Health Care Classification has been tested and used since 2003 in one Central Hospital and two Health Care Centers.