A systematic literature review of accuracy in nursing care plans and using standardised nursing language

Abstract Background Care planning is an essential part of nursing practice. Formulating nursing care plans within the framework of standardised nursing language warrants further examination. Aim The aim of this systematic review was examine the available literature related to nursing documentation and care plans, in relation to the impacts of using standardised nursing language. Methods The electronic databases of Medline and Cumulative Index to Nursing and Allied Health Literature were searched using predetermined search strategy. A narrative synthesis was undertaken. Findings Of the 198 articles identified 21 articles were included in the review. Discussion The examination of the available evidence suggests that a global and Australian difference in use of standardised nursing language in nursing care planning and documentation, including research related to nursing documentation exists. Conclusion There are major benefits for systematically integrating nursing classification systems and standardised nursing language. Standardised nursing language is essential for the successful integration of nursing documentation into contemporary healthcare where electronic health care records will be the norm.

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