Implementing the use of nursing diagnosis in a university hospital setting

Staff development instructors often are responsible for teaching and implementing nursing process and documentation policies. The Staff Development Department at the University Hospital devised a documentation system that centers around nursing diagnoses approved by the North American Nursing Diagnosis Association. This system incorporates nursing diagnosis terminology into the nursing care plan and progress report. Evaluation of the care plan is documented in the progress report using either a narrative format or systems approach format of documentation. The program planning, implementation, and evaluation phases are presented. Content overview and cost analysis provide a useful reference for staff development departments.