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This study tried to suggest the basic materials that can be efficiently applied in clinical cases by understanding problems through a content analysis of an adult nursing assessment tool and opinion agreement about nurse’s practical usage presently used in the hospital. The study was carried out in 36 attached hospitals in nationwide universities from May to December, 1999, the two hundred and twenty five reports were for analysis. The contents of the collected nursing assessment tool were analyzed. It was found that the tool had been used with various names and content and there were instances of partial omission of a number of items, such as documentation and time records. Other results revealed that they mostly had a systematic classification of items, formation of details a form of a check list, and the effect of saving time. In spite of the adult nursing assessment tool, it was suggested that its style be subdivided according to the specialized of a department and that standardized style be amended and supplemented. The respondents also answered that there had to be education about continuous and sufficient health assessment skills on the physical examination record. The most frequently suggested items to be added were: past history, marital status, patient and caregiver’s address and telephone number. It was found that a patient’s education career, economic status, religion, hygienic practice, sexual life and hobby were the most frequently omitted items on record. The reason given wes because the items were associated with his/her privacy. These results highlight the importance of analyzing the content with an complete data collection, supplying basic content for a more accurate nursing record, computerization, sharing information and standardization of the form.
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