Analysis of nursing records of cardiac-surgery patients based on the nursing process and focusing on nursing outcomes

Summary 

This study analyzed what nurses wrote in narrative nursing notes for cardiac-surgery patients. The nursing notes of 46 patients were analyzed based on the nursing process. Eight patterns were extracted according to different combinations of nursing process components, of which an assessment alone was the most frequent nursing phrase (45.8%), followed by assessment or diagnosis-intervention-outcome (25.9%). The content of the nursing notes was also classified into 15 categories, of which nursing outcomes were recorded more frequently in nursing care driven mainly by physician's order such as disease-related symptom management, insomnia care, respiratory care, and pain control, than in independent nursing care such as education and emotional care. A survey on the attitudes of nurses toward the nursing record revealed that they do not document nursing outcomes as much as they think they do. The main reasons for this discrepancy were insufficient time for recording and lack of knowledge about why, how, and what to evaluate. Even though there is room for improvement, nursing notes represent a useful resource for determining nursing contributions to patient outcomes.

Keywords: Nursing records, Nursing process, Nursing documentation, Nursing outcome, ICNP, Outcomes research, Cardiac-surgery