Nurses' Own Recordkeeping: The Nursing Minimum Data Set Revisited

There is no consistent, standardized, concise method for nurses to record information about their patients and clients that is conducive to store, retrieve, and use in patient and client care; to improve professional self-development; and to use in collaboration with patients and clients, their families, other nurses, doctors, hospitals, and health systems. Nurses gauge the health status of their patients and clients every day and are now in a position both to record their impressions for their own use and to share them with colleagues who care for the same patients and clients. What is now needed is a way to record these clinical impressions within an authoritative format that is related to the depth and breadth of the clinical literature related to nursing and the needs of the patients and clients nurses serve. The International Council of Nurses' Nurse-Patient Summary is proposed here to fill the gulf between narrative nurses' notes, proprietary and widely varying electronic health record systems, and information from nurses about their patiens and clients human needs. The International Council of Nurses' Nurse-Patient Summary could replace nursing diagnosis items in the Nursing Minimum Data Set and serve as a substitute for the World Health Organization's International Classification of Function, Disability and Health, a seldom used instrument derived from the International Council of Nurses' Basic Principles of Nursing Care.