Nursing language, Care map, Patient outcomes



  1. McDaniel, Anna M. DNS, RN


The purpose of the two pilot studies described in this article was to develop and evaluate a database for managing patient care information. A retrospective review of medical records for 67 patients was used for capturing nursing information. Three categories of data were obtained: (1) patient problems,(2) nursing interventions, and (3) patient outcome achievement. A total of 439 patient problems were identified. A total of 4541 discrete nursing interventions were coded, with assessment and surveillance activities accounting for 26% of the total. The degree to which targeted patient outcomes were achieved was assessed by analyzing documentation of patient outcomes in the medical record. Of 2326 expected patient outcomes identified, only 55% (1272) were documented as "met" in the medical records. Potential uses for the database include outlier analysis and outcomes assessment in specific patient populations.