. 2015 Aug 6;2(3):97–104. doi: 10.1002/nop2.22

Table 1.

Code scheme

Observation	Was used for when the nurse observed and also documented something. This could be something that the nurse discovered by herself or something that the nursing assistant drew her attention to.
Screening	Was used when the nurse, e.g. took a blood test, blood pressure or urine test.
Engage in waiting	Was used when the intervention was to wait and this was clearly stated in the documentation. Could be for a shorter or a longer period of time.
Follow‐up	Was used when the nurse followed up on a previously described observation. It was also used when the nurse checked for a test result or did a follow‐up on a resident who was admitted to hospital.
Nurse prescribed action	Was used when the nurse, e.g. attended to catheters, handed out medicines or cooled down a warm room. Was seen as being prescribed by the nurse herself or as a part of “standard care”.
Diagnosing	Was used when the nurse documented a diagnosis or a probable cause of a problem. This includes establishing that an elderly person was tired and that the cause could be a side effect of a certain medicine. It could also be when the nurse established a cold.
Contacting the physician	Was used for rounds or for when the nurse initiated a contact herself outside scheduled time.
Carrying out an action prescribed by the physician	Was used when the nurse did what the physician prescribed.
Nothing happens	Was used when the nurse did not document anything, even though the nursing assistant seemed concerned for an elderly person. It was also used when there seemed to be an interlude in the documentation during an episode. This was only coded when nothing happens for a whole day and night.
Contacting an ambulance or arranging an emergency visit to the hospital	Was used when the elderly person was acutely sent to hospital.
Prescribing screening	Was used when the nurse prescribed a screening for later on. This could include contacting the physician the next day, taking a temperature in the evening or measuring a blood pressure the next morning.