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.

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