Riv Inferm. 1991 Jan-Mar;10(1):20-5.
Quality of symptoms registration on three different models of nursing records was reviewed to assess whether a more patient oriented nursing record could influence completedness and precision of symptoms registration. A group of nurses set minimum criteria for five symptoms (pain, emesis, diarrhea, fever and constipation), according to the nursing process: description of written registrations of 517 symptoms were assessed. No differences appear to exist among the three different models of records, except for evaluation of the results of the interventions, more reported in the patient oriented nursing records.
回顾了三种不同护理记录模式下症状记录的质量,以评估更以患者为导向的护理记录是否会影响症状记录的完整性和准确性。一组护士根据护理流程为五种症状(疼痛、呕吐、腹泻、发热和便秘)设定了最低标准:对517条症状的书面记录描述进行了评估。除了干预结果的评估在以患者为导向的护理记录中报告得更多外,三种不同的记录模式之间似乎没有差异。