Determining Objective Data Use in Intensive Care Patients' Nursing Records

• Published in: International journal of caring sciences Vol. 10; no. 2; p. 736
• Main Authors: Coskun, Ela Yilmaz, Yildiz, Guldem, Capar, Eda, Serbest, Sehriban, Karabacak, Ukke
• Format: Journal Article
• Language: English
• Published: Nicosia Professor Despina Sapountzi - Krepia Publisher of the International Journal of Caring Sciences 01-05-2017
• Subjects: Archives & records; Critical care; Data collection; Intensive care; Medical records; Nurses; Nursing care; Patients; Physicians
• ISSN: 1791-5201; 1792-037X

This study aimed to determine objective data use in the nursing care plans and nursing notes of intensive care patients. The sample of the study consists of nursing care plans and nursing notes of 228 patients. The data of the study were obtained through the investigation of the last year's intensive care patient records, which were generated by the nurses. It was found that the nurses wrote 798 nursing diagnoses for 228 patients, and in 67.3 percent of these diagnoses, objective data were not included. It was concluded that the nurses do not reflect the objective data they stated in nursing notes to care plans. It is recommended that skills of the nurses must be increased, whether the nursing process efficiently managed and implemented in nursing care plans must be controlled.