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Guidelines for Nursing Documentation I

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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.

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Guidelines for Nursing Documentation II

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Updated: Jun 21, 2026

A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings

A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings

Published on: November 9, 2016

Narrative text in structured documentation of medication risks and side effects.

Virpi Jylhä¹, Kaija Saranto

¹University of Kuopio, Department of Health Policy and Management Kuopio, Finland. virpi.jylha@uku.fi

Studies in Health Technology and Informatics

|July 14, 2009

Summary

Nurses using the Finnish Care Classification (FinCC) often supplement structured data with narrative text. However, this text frequently lacks alignment with FinCC codes and the nursing process, indicating a need for improved training in structured documentation.

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Published on: September 20, 2018

Area of Science:

Health Informatics
Nursing Informatics
Clinical Documentation

Background:

Electronic patient records (EPRs) facilitate data utilization for clinical, administrative, and research aims.
Effective EPR use necessitates structured documentation models employing standardized nursing classifications.
The Finnish Care Classification (FinCC) is a structured nursing classification system based on the Clinical Care Classification.

Purpose of the Study:

To analyze how nurses utilize narrative text to supplement medication risk and side effect documentation within the FinCC framework.
To evaluate the consistency between narrative text content and FinCC codes.
To assess adherence to the nursing process in narrative documentation.

Main Methods:

Analysis of narrative text used by nurses alongside the Finnish Care Classification (FinCC) version 1.1.
Examination of documentation related to medication risks and side effects.
Evaluation of the correspondence between narrative content and FinCC codes, including nursing diagnoses and interventions.

Main Results:

Narrative text content frequently does not align with the applied FinCC codes.
The documentation in narrative text does not consistently follow the established nursing process.
Nurses encounter particular difficulties in effectively utilizing nursing diagnoses within the structured documentation system.

Conclusions:

There is a clear need for enhanced continuing education programs focused on structured documentation practices for nurses.
Further research is required to explore the relationship between nursing diagnoses and interventions.
Additional investigation is needed to understand how other documentation components are supplemented by narrative text.