title: Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting.
abstract: OBJECTIVE
  This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology.
  
  
  METHODS
  An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review.
  
  
  RESULTS
  Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans.
  
  
  CONCLUSIONS
  The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care.
  
  
  CONCLUSIONS
  The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care.
authors.affiliation: IDIBELL Institute of Research, Nurse coordinator, Catalan Institute of Health. Associate professor, University of Barcelona School of Nursing - Health Universitat de Barcelona Campus, Barcelona, Catalonia, Spain.
authors.forename: Maria-Eulàlia
authors.initials: ME
authors.lastname: Juvé-Udina
authors.forename: Esperanza Zuriguel
authors.initials: EZ
authors.lastname: Pérez
authors.forename: Núria Fabrellas
authors.initials: NF
authors.lastname: Padrés
authors.forename: Maribel Gonzalez
authors.initials: MG
authors.lastname: Samartino
authors.forename: Marta Romero
authors.initials: MR
authors.lastname: García
authors.forename: Mònica Castellà
authors.initials: MC
authors.lastname: Creus
authors.forename: Núria Vila
authors.initials: NV
authors.lastname: Batllori
authors.forename: Cristina Matud
authors.initials: CM
authors.lastname: Calvo
mesh_terms: D003142:Communication; D064648:Critical Care Nursing; D057286:Electronic Health Records; D006801:Humans; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000706:statistics & numerical data*; D010347:Patient Care Planning; D011613:Psychotherapy / Q000706:statistics & numerical data*; D012189:Retrospective Studies
keywords: ATIC terminology; Basic nursing care; Communication; Fundamentals of care; Nursing interventions; Nursing language systems; Psychosocial care