Documentation: short, simple, and meaningful

Nursing diagnosis has been incorporated into the documentation in our neonatal units because it gives nurses credit for their unique functioning, provides for consistency in communication, facilitates continuity of care, and is therefore likely to improve the quality of nursing care. The documentation system utilizes flow sheets to document physiological functioning. The nursing progress note/individualized patient care plan provides for a narrative note and continuous update of the patient care plan, keeping it current and meaningful. Previous care plans have involved massive writing about nursing actions. By providing reference tools that list the actual nursing actions, this system allows the nurse's written documentation to describe what the focus of the nurse's work has always been: the patient and the patient's responses to nursing care.