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Table 2 Forms and location of nursing data needed for the NMDS-AT in the analysed patient records (n = 20)

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