From: Implementation of the Austrian Nursing Minimum Data Set (NMDS-AT): A Feasibility Study
 | Form of documentation | Location in patient record | |
---|---|---|---|
Nursing diagnoses | nursing classification system | electronic | nursing care plan |
Nursing interventions | nursing classification system or free text notes | electronic or paper-based | nursing care plan, nursing report, specific forms or fever chart |
Nursing outcomes | check boxes or free text notes | electronic or paper-based | nursing assessment, specific forms, discharge letter or fever chart |