Quality of nursing records and standardized language: literature review
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Keywords

nursing records. nursing diagnosis
information technology.

Abstract

Abstract. Context. The time spent to produce nursing records, to become aware of the policy of the institution, to use standardized nursing language, as well as the tools available (printed or electronic tools) may directly interfere on quality of nursing records. Objective. To identify and analyze the literature data on factors that affect the quality of nursing records and the use of standardized language. Methods. Literature review was conducted in the databases CINAHL, PubMed and SciELO. For selecting the texts for review, abstracts and available full texts, in Portuguese or English, about the subject were read. Result. This review allowed to evidence that the quality of nursing care is directly related to the quality of professionals’ records. Additionally, appropriate use of standardized language combined with electronic tools is helpful for nurses and their teams on the care provided. Conclusion. In the near future, standardized electronic documentation will allow remote and recurring access to data among different health professionals and organizations. Relevance to clinical practice. This fact can improve patient care, as well as it can assist the development of clinical protocols and researches. Improvement of nursing records is still a challenge for nurses.

https://doi.org/10.5935/1676-4285.20103088
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