Abstract
Since the 1980’s, questions have been asked the world over about the efficiency and contribution of nursing in the hospital treatment of patients and nursing performance within the framework of nonhospital health care. The cause for these tendencies has many roots. For one, we can determine a push in professionalism through the increasing importance of nursing sciences on whole. The basic focus is on comparability, standardization (Johnson et al., 2005), and securing quality (ICN, 2003). Also, a significant part of nursing systems internationally are publicly financed and legally determined. This has the consequence that the political decision-makers, particularly in context with the financing and planning of nursing structures, have more of an interest in controlling the nursing systems and disposing of useable nursing data.
Key Terms in this Chapter
Nursing Classification: Or nursing classification system. A catalogue structuring nursing action. The focus is on nursing diagnosis (NANDA), nursing intervention (NIC), or nursing outcome (NOC). All classification systems intend to be a basis for possible quantification and also comparability of nursing performance.
Nursing Documentation: Contains more than the registration of delivered nursing action. A complete nursing documentation also comprises the assessment, plan, and evaluation—altogether representing the nursing process.
Nursing Process: A concept of how nursing care should be provided from a nurses’ point of view. The nursing process was internationally published by WHO in the 1980s and originally consisted of four steps (assess, plan, intervene, evaluate). Due to its importance, documentation was additionally introduced to the nursing process.
Nursing Minimum Data Set (NMDS): Dependent on the regional scientific background, NMDS is used for the concept of a data structure or a list of nursing interventions being documented in a nursing documentation system.
Nursing Terminology: A nomenclature which enables the comparability of nursing performances.
Documentation System: An IT-Tool to register nursing action; nevertheless, this system can still be paper based.