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Introduction: Documentation of nursing care and procedures is an evidence of performance and quality of these cares. Failure to document could be a sign of inadequate care performance.

Method and Materials: This study was carried out to determine causes of inadequate nursing documentation in wards of Shahid Beheshti Hospital, Zanjan, in 2003. This study was a descriptive survey a checklist was designed according to standard principles of nursing documentation which was validated by 10 academic members. Patients&apos files were assessed based on this checklist. Also, 20 nurses were interviewed (open question) to determine of causes of incorrect nursing documentation.

Results: The results showed that 17% of items of checklist had been documented correctly, documentation’s of 35.81% of these items were incomplete and 48% of items had not been documented. The interviews showed that the inadequate nursing documentation was related to inattention to these documentation’s and lack of control of nursing documentation, work overload of nurses, educational problems and unawareness of legal and occupational issues.

Conclusion: Documentation of nursing care was inadequate. The most important causes were inattention and lack of control. Considering importance of nursing documentation, ways to solve these problems must be sought.

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Background & Aim: Proper recording of the nursing report indicates the nurse’s optimal clinical performance and compliance with the standards. Nanda Nursing Diagnosis is one of the most important and widely used international standard terms for recording nursing care. The aim of this study was to determine the degree of compliance and frequency of nursing diagnoses registered in the pediatric oncology department with the statements of nursing diagnoses of the Nanda classification system.
Methods & Materials: In this descriptive study, the nursing reports recorded in the files of children hospitalized in the pediatric oncology wards of two hospitals affiliated to Shahid Beheshti University of Medical Sciences in the first quarter of 2016, were reviewed. Sampling was done by the census method for 3 consecutive months. Overall, 86 files and 3701 nursing reports were reviewed. Nurses' documentation was analyzed through the manifest content analysis. The obtained expressions were adapted to the nursing diagnoses of the Nanda classification system and the degree of adaptation and frequency of nursing diagnoses were determined.
Results: The overall compliance between the diagnoses extracted from the nursing reports and the Nanda nursing diagnoses was 14.7%. The most frequent nursing diagnoses were diagnoses related to safety/protection classification with a frequency of 47.95%, followed by diagnoses related to nutrition classification with a frequency of 24.42% and finally a frequency of 12.8% for nursing diagnoses related to comfort classification.
Conclusion: The findings of the present study indicated the low levels of compliance with the Nanda nursing diagnoses and nursing process in the nursing reports. Therefore, practical training is suggested to increase nurses' knowledge and motivation to apply Nanda nursing diagnoses.