This final thesis was commissioned by a primary health care ward in southern Finland, in which the recording practice relating to nursing work is being upgraded in compliance with the eNNI project. The purpose of the final project was to chart and describe the ward’s present recording procedure. The aim was to produce information on the content of the recording of nursing work, on how the nursing process is presented in the recording of nursing work, on the sources of information required in nursing, and on how the recorded information is utilised. By means of the information, the nursing staff is able to assess and improve the recording procedure, when switching to structured recording. They are also able to plan possible changes and their own need for training relating to recording. The compatibility of patient information systems will be guaranteed by using essential, structured treatment data describing the patient’s treatment through the phases of therapeutic decision-making. For this, it is important to understand the nursing process.

The material was gathered using the theme interview method. Four registered nurses and four practical nurses or care assistants working under the title of practical nurse took part in the interview. The material was analysed from deductive point of departure, and the analysis was continued by means of inductive content analysis. According to the results, the nurses recorded the data well, when the patient entered the ward. The implementation of nursing work was also recorded comprehensively. In some cases, the recording of the nursing work’s planning and assessment were experienced as difficult and inadequate. The recorded information was used in nursing work in many ways, but it could not always be utilised to sufficient extent. Lack of space for the planning and assessment of nursing and insufficiency of recording were experienced as factors preventing recording.

A development target is familiarisation with recording complying with the nursing process, which would make it easier in the future to structured recording.