Patients' Care Needs: Documentation Analysis in General Hospitals.

Area of Science:

• Nursing
• Healthcare Informatics
• Patient Care Documentation

Background:

• Accurate identification of patient care needs is crucial for effective nursing interventions and high-quality outcomes.
• The NANDA-International (NANDA-I) classification system provides a standardized framework for nursing diagnoses.
• Understanding how nurses document and classify patient needs is essential for improving care delivery.

Purpose of the Study:

• To describe the care needs of patients in Dutch hospitals based on nursing documentation.
• To evaluate the extent to which nurses utilize the NANDA-I classification system in formulating these care needs.

Main Methods:

• A stratified cross-sectional random-sampling nursing documentation audit was performed.
• The D-Catch instrument was employed across 10 hospitals, encompassing 37 wards.
• Data were collected to analyze documented patient care needs and the application of NANDA-I.

Main Results:

• The most frequently identified nursing diagnoses included acute pain, nausea, fatigue, and risk for impaired skin integrity.
• A significant proportion of documented care needs were categorized within physiological health patterns.
• Fewer care needs were identified and documented within psychosocial health patterns.

Conclusions:

• Nursing documentation in Dutch hospitals primarily reflects physiological care needs.
• There is a need for nurses to expand their diagnostic focus to include psychosocial and other patterns for comprehensive patient care.
• Integrating a broader range of NANDA-I patterns, such as health management, value-belief, and coping stress, can enhance nursing interventions and improve nursing-sensitive outcomes.