Evaluation of nursing process documentation

Following the introduction of a nursing process and associated documentation in one hospital, an attempt was made to evaluate the effectiveness of the documentation as a record of the nursing process. Two questionnaires were developed, based on previous research in this field, one for the assessment of the documentation, and the other to assess the attitudes and practices of the ward sisters regarding its implementation. The findings indicated that, generally, the assessment phase of the process was poorly documented and that many psychological and social problems were not addressed as well as others. The interventions were relevant but contained little detail. The evaluation section was fair but updating and re-assessment where relevant were poor. Some sisters seemed to display a lack of understanding of the principles or the practice of the process, despite in-service education. Lessons to be learnt from the exercise are suggested.