University Campus Bio-Medico, 200-00128 Rome, Italy.
J Clin Nurs. 2010 Jun;19(11-12):1544-52. doi: 10.1111/j.1365-2702.2009.03012.x. Epub 2010 Apr 20.
The aim of this study is to evaluate the consistency between the care given to patients and that documented, by comparing care observations with nursing records and describing which interventions were reported and which were omitted.
Assumptions have been made about the relationship between documentation and care actually delivered, but there is insufficient evidence on the relationship between the actual care given and its recording.
Observational study of the care given, completed by interviews and retrospective survey of records.
Structured observation during day shifts in the first six days of admission of pre and postsurgical care provided to 21 consecutive patients undergoing major abdominal surgery and audit of their nursing records. Each observation was completed by short interviews to nurses to ensure observations validity.
Only 40% of nursing activities observed were included in the nursing records (37% of the assessments and 45% of the interventions). This indicated that nurses carry out more activities than they report. Consistency between performed and recorded care decreased significantly during the days when a higher number of activities were performed. Consistency between recording and observation of assessment activities was 38% for physical needs and 0% for educational needs. Consistency was higher for the assessments of physical signs/symptoms and risk factors for complications compared to the assessment of basic needs and pain. Consistency was 47% for technical interventions and 3% for educational activities.
Nursing records were not found to be an adequate tool for quality care evaluation, because they did not include all the caring activities that the nurses had carried out.
This study supports the need to identify documentation systems that are easy to complete. Moreover, nursing education should pay more attention to the competences in the field of holistic care and patient education.
本研究旨在通过比较护理观察与护理记录，评估护理人员所提供的护理与记录之间的一致性，并描述哪些干预措施被记录，哪些被遗漏，从而评估护理人员所提供的护理的一致性。
人们对记录与实际提供的护理之间的关系做出了假设，但关于实际提供的护理与其记录之间的关系，证据不足。
对护理人员提供的护理进行观察性研究，通过访谈和回顾性调查记录来完成。
对 21 例接受腹部大手术的择期手术和术后护理的患者，在入院后的前 6 天进行日间班次的结构化观察，并对他们的护理记录进行审核。每次观察结束后，对护士进行简短访谈，以确保观察的有效性。
只有 40%的观察到的护理活动被记录在护理记录中（37%的评估和 45%的干预措施）。这表明护士的实际护理活动比记录的多。当执行的护理活动数量增加时，护理记录与实际护理的一致性显著下降。在实际护理和观察到的评估活动之间，身体需求的一致性为 38%，教育需求的一致性为 0%。对身体体征/症状和并发症风险因素的评估与对基本需求和疼痛的评估相比，记录与观察的一致性更高。技术干预的一致性为 47%，教育活动的一致性为 3%。
护理记录并不是评估护理质量的有效工具，因为它没有包括护士实际执行的所有护理活动。
本研究支持需要确定易于完成的记录系统。此外，护理教育应更加关注整体护理和患者教育领域的能力。
