Purpose: This study aims to identify NANDA-I nursing diagnoses that midwives working in obstetrics and gynecologic service use while managing the electronic nursing care process.
Methods: This retrospective study was conducted in a descriptive way to evaluate electronic care plan records of 3025 patients staying in obstetrics and gynecologic service between April 1, 2020. and April 1, 2021. Diagnoses in the records of the electronic care process were digitalized by two faculty members. Then, NANDA-I nursing diagnoses used by midwives were identified. NANDA-I nursing diagnoses used by midwives were identified.
Findings: It was determined that diagnoses in care plans documented from the system within the 1-year period fell into eight domains and 10 classes, and 5819 diagnoses were given in total. The most frequent diagnoses given in obstetrics and gynecologic service were "acute pain" and "risk for bleeding."
Conclusion: Findings of this study revealed that nursing care records in obstetrics and gynecologic service did not have a large number of diagnoses and interventions.
Implications for nursing practice: Care plans directly reflect the contribution of the care to the patient. Consequently, midwives being aware of and recording nursing diagnoses while giving care will ensure a standardized language and visibility in care. More coverage of midwifery-related diagnoses in the midwifery curriculum will make NANDA-I nursing diagnoses more visible in midwifery as well.
Keywords: electronic health records; midwifery; midwifery record; nursing diagnoses; standardized midwifery language.
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