The aim of this article is to examine the relationship between nursing practice
and the recording of practice. We outline the main findings of a Cochrane
systematic review on nursing records, discussing the indications from the
included studies that compared computerized nursing care planning with
paper-based systems. Qualitative research on nursing records systems, and other
survey evidence, is collated to answer questions on the format of the record
(structured versus free text, for what type of practice), occasions when
information exchange about nursing care may not and should not be recorded
formally, and the effective organization of the nursing record. We conclude that
more research is required to answer these questions, as it seems that
computerization does not always bring the expected benefits, and outcomes for
patient care are not clear.