Abstract

There is a growing level of activity supporting the development of a taxonomy for nursing diagnoses, interventions, and outcomes. While this development is occurring at a theoretical level, more work is necessary at a clinical level in order to determine how these concepts are being operationalized; more specifically, to establish whether there is a link between assessment, diagnosis and interventions documented in the patient's medical record. Using a retrospective audit this research reviewed 304 patient records. The study data revealed that the nursing diagnoses documented were not always supported by patient assessment information. It also illustrated inconsistent links between the documented nursing diagnosis and interventions. These findings challenge the a priori support for nursing diagnosis forming the basis for patient care, as it exposes clinical application weaknesses. Given the International Council of Nurses move to develop and evaluate an International Classification of Nursing Practice, these weaknesses need to be considered in any evaluation.