Models, standards and structures of nursing documentation in European countries Asta THORODDSEN a , Kaija SARANTO b, Anna EHRENBERG c , Walter SERMEUS d a Faculty of Nursing, University of Iceland, Iceland b Department of Health Policy and Management, University of Kuopio, Finland c Department of Health and Social Science, Högskolan Dalarna, Sweden d Department of Public Health, Catholic University Leuven, Belgium Abstract. The use of standardized nursing languages varies between and even within different European countries. Standardization of a nursing language is a demanding process which requires substantial methodological and technological knowledge as well as cultural experience in terminology development work. A survey was carried out to describe the current state of art of the use of models, standards and structures in nursing documentation. A web-based questionnaire was targeted to members of the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO). Replies were received from 17 countries in Europe. Results show that the nursing process is the model most often used to structure nursing documentation in Europe. Many standardized nursing terminologies are used in Europe but general use in nursing is still lacking which makes access to nursing data an obstacle. In more than 60% of the institutions in the countries that replied were nursing data not stored and could therefore not be retrieved. These results should be a major concern to nurses in Europe. This relates to the lack of use of standards in use of nursing terminologies and information systems. Standardization activities in existing and evolving networks in Europe, as well as in other parts of the world, need to be enhanced. As a European platform, ACENDIO can play a role in these standardization activities and should develop its role accordingly. Keywords: Standards, EHR, Terminology, Classification 1. Introduction The standardization of nursing language has been in process already for many years. However, standardized structures and terminologies for nursing recording are not very common within European countries [1,2]. The most common model to structure nursing notes in health records is the nursing process model presented by the World Health Organization (WHO) [3]. According to the model the nursing process can be divided into four up to six phases based on the decision making theory. Assessment, planning, intervention and evaluation are the most commonly used phases in the decision making process. Nursing diagnosis has been added as an independent phase after assessment in many countries to emphasize the importance of naming the outcomes of assessment [4,5]. Many countries have followed the development work of the International Council of Nursing (ICN) and their extensive product the International Classification of Nursing Practice (ICNP) [6]. The NANDA classification has also been translated into many European languages, as for example French, Spanish and Dutch [7]. Since 1995 the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO) has offered a platform for discussion on terminology activities in the European countries. Standardization of nursing language has been the leading topic among members. ACENDIO Standardization Committee has three major objectives for its European wide activities: 1) the translation of terms used to describe nursing diagnoses, interventions and outcomes, 2) promoting compatibility with ICNP and cross-mapping of national terms and classification systems, 3) receiving and reviewing proposed diagnoses, interventions and outcomes, and 4) promoting means