Riv Inferm. 1991 Jan-Mar;10(1):13-9.
Steps of the implementation of a nursing record in a general medical ward of S. Carlo Hospital (Milano) are reported: from the planning, to the experimentation to the evaluation of how the records were used. Nursing records were used on 63 patients admitted to the ward over a two months period, evaluation methods used were Phaneuf nursing audit and nurse-doctor communication on some common-managed problems. According to Phaneuf audit, quality of nursing care is incomplete, while, for the 23 problems examined, written evidences were found of integration of nursing and medical care.
从规划到试验,再到对记录使用情况的评估。在两个月的时间里,对该病房收治的63名患者使用了护理记录,所采用的评估方法是法纳夫护理审核以及就一些共同处理的问题进行护士与医生之间的沟通。根据法纳夫审核,护理质量不完整,而在所检查的23个问题中,发现了护理与医疗整合的书面证据。