Using and documenting nursing diagnosis in an ambulatory setting.

Area of Science:

• Nursing
• Healthcare Informatics

Background:

• Nursing documentation is crucial for efficient communication and resource utilization.
• Ambulatory care settings present unique documentation challenges.
• The effectiveness of nursing diagnosis in outpatient settings requires investigation.

Purpose of the Study:

• To explore nursing documentation practices in ambulatory care.
• To assess the applicability of nursing diagnosis in outpatient settings.
• To describe the development of a novel documentation tool for ambulatory nursing.

Main Methods:

• Development of a unique documentation tool tailored for ambulatory care.
• Implementation of the tool within a healthcare agency.
• Evaluation of the tool's impact on nursing diagnosis use and communication.

Main Results:

• The developed tool facilitates and encourages the use of nursing diagnosis by various nursing roles.
• Improved communication among nursing personnel was observed.
• The tool demonstrated potential for effective nursing diagnosis application in ambulatory settings.

Conclusions:

• A specialized documentation tool can successfully integrate nursing diagnosis into ambulatory care.
• Enhanced communication and resource utilization are potential benefits.
• This approach supports nurses in clinic and day hospital settings.