EVALUATION OF NURSING PROCESS DOCUMENTATION

Following the introduction of a nursing process and associated documen tation in one hospital, an attempt was made to evaluate the effectiven ess of the documentation as a record of the nursing process. Two quest ionnaires were developed, based on previous research in this field, on e for the assessment of the documentation, and the other to assess the attitudes and practices of the ward sisters regarding its implementat ion. The findings indicated that, generally, the assessment phase of t he process was poorly documented and that many psychological and socia l problems were not addressed as well as others. The interventions wer e relevant but contained little detail. The evaluation section was fai r but updating and re-assessment where relevant were poor. Some sister s seemed to display a lack of understanding of the principles or the p ractice of the process, despite in-service education. Lessons to be le arnt from the exercise are suggested.