Towards basic nursing information in patient records

Abstract

Four key concepts for good nursing care and a list of key words for nursing documentation in patient records were established and to some extent tried in clinical practice in Sweden. The method consisted of the following steps: extensive literature review, review of nursing records, development of a list of key words on two levels, a first level corresponding to the nursing process, and a second level consisting of subdivisions for possible use in practice, use and assessment in clinical practice by nurses and students, expert panel judgement and refinement of the key words including an examination of semantic accuracy of the Swedish key words by an expert in Nordic languages. The proposed key words are presented both in English and Swedish and explanations, comments and references are given. The version of key words presented here is subject to further testing for possible modifications.