Using and documenting nursing diagnosis in an ambulatory setting.

Abstract

Documentation and the use of nursing diagnosis have proved to be important in increasing the efficiency of communication and the clarification of nursing services provided. This has led to better utilization of nursing resources. The increased emphasis on ambulatory care has shifted our focus to nurses' roles in clinic and day hospital settings. How do nurses document the care they provide in an ambulatory setting? Can nursing diagnosis be used as effectively in the outpatient department as it has been in the acute or chronic inpatient hospital setting? This article describes how one agency developed a unique documentation tool for ambulatory care which allows for and encourages the use of nursing diagnosis by staff nurses, IV nurses and nurses in expanded roles, and facilitates communication among all nursing personnel.