This study aimed to: 1) determine the core nursing interventions, and 2) compare acute interventions with subacute interventions recorded in the nursing notes of patients with cerebrovascular accidents (CVA).

The nursing records covering the first 10 days of 30 patients with a CVA who were admitted from January to December 2004 at C University Hospital in Korea were examined. Data was collected using the nursing interventions classification (NIC) from January to April 2005. Finally, data analysis was carried out using mean, SD, and paired t-test according to domains, classes, and interventions.

The most frequent nursing intervention at both stage was “Neurologic monitoring”. There were differences in interventions belonging to the “Physiological: complex,” “Behavioral,” “Safety,” and “Health system” domains between the acute and subacute stages. The frequency of interventions belonging to the “Immobility management,” “Neurological management,” “Tissue perfusion management,” “Patient education,” “Risk management,” “Health system mediation,” and “Information management” classes at the acute stage was higher compared to the subacute stage.

This study found out that nurses relatively recorded more nursing interventions during the acute stage hence the unsuccessful documentation of the subacute stage particularly in describing the specific nursing interventions at this stage.

The purposes of this study were to determine the core nursing interventions in nursing notes and the practice which was perceived by nurses of an oncology unit with patients with terminal cancer. Also, comparing interventions in nursing notes with interventions in perceived practice was done.

Subjects were 44 nursing records of patients with terminal cancer who had died from Jan. to Dec. 2002 at C University Hospital and 83 nurses who were working on an oncology unit for more than one year. Data was collected using a Nursing Interventions Classification and analyzed by means of mean and t-test.

The most frequent nursing intervention was ‘nausea management’ in the nursing note and was ‘medication administration : oral’ in perceived practice. The frequency of nursing interventions in the nursing record was lower than in perceived practice.

This study finds that nurses actually practice nursing care, but they may omit records. To correct for omitted nursing records, development of a systematic nursing record system, continuous education and feedback is recommended.