Abstract:
The purpose of this study was to assess the effects
of changing a nursing documentation system, developed
from King's Conceptual Framework, on the use of the
nursing process. The null hypothesis was that there
would be no significant increase in the reflection of
the use of the nursing process on the nursing care plan
or nurses' notes, as a result of using a nursing
documentation system developed using King's Conceptual
Framework (1981).
The design involved the development of a
questionnaire that was used to review health records
pre and post implementation of a documentation system
developed based on King's Conceptual Framework and
Theory of Goal Attainment (1981). A Record
Completeness Score was obtained from some of the
questions. The null hypothesis was rejected.
The results of the study have implications for
nursing administration and the evaluation of nursing
practice. If the use of a documentation system
developed from a conceptual framework increases the
reflection of the nursing process on the patient's
health record, nursing will have the means to measure patient outcomes/goal attainment.
All health care organizations and levels of
government are focusing on methods to monitor and
control the health-care dollar. In order for nursing
to clearly determine the costs associated with nursing
care, measurement of patient outcomes/goal attainment
will need to be possible. In order to measure patient
outcomes/goals attainment nurses will need to be able
to collect data on their practice. It will be critical
that nursing have a documentation system in place which
facilitates the reflection of the nursing process
within a theoretical framework.
