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Ene
versión On-line ISSN 1988-348X
Resumen
RODRIGUEZ-SUAREZ, Claudio Alberto et al. Use of standardised Nursing terminology at discharge care reports in a Canary Islands hospital: a descriptive study. Ene. [online]. 2023, vol.17, n.2, 2217. Epub 22-Ene-2024. ISSN 1988-348X.
Objectives:
To analyse the use of standardised language in nursing care reports identifying typologies, labels and diagnostic content.
Methods:
Cross-sectional descriptive study of a simple random sample (n = 370) in the Complejo Hospitalario Universitario Insular Materno-Infantil (Canary Islands, Spain). The mean and standard deviation for quantitative variables, and frequency for qualitative variables were calculated using SPSS® (version 25).
Results:
Less than half of the reports (49.23%) incorporated standardized terminology, including n = 1922 active diagnoses, n = 93 resolved diagnoses, n = 72 interventions, and n = 103 nurses outcomes.
Conclusions:
Reports using standardized languages are insufficient, showing a high number of diagnostic labels that reveal poor resolution of problem-focused nursing diagnoses, with less recording of interventions and nurses outcomes.
Palabras clave : Nursing Diagnosis; Electronic Health Records; Patient Discharge Summaries; National Health Systems; Standardized Nursing Terminology.
