Degree in Nursing & Midwifery Sciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy.
Department of Experimental Medicine, University of Perugia, 06123 Perugia, Italy.
Int J Environ Res Public Health. 2020 May 7;17(9):3259. doi: 10.3390/ijerph17093259.
Nursing documentation is an important proxy of the quality of care, and quality indicators in nursing assessment can be used to assess and improve the quality of care in health care institutions. The study aims to evaluate the completeness and the accuracy of nursing assessment, analyzing the compilation of pain assessment and nutritional status (body mass index (BMI)) in computerized nursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis related group weight (DRG), seniority of charge nurse, and type of ward (medical, surgical or other). The observational ecological pilot study was conducted between September and October 2018 in an Italian Tertiary-Level Teaching Hospital. The nursing documentation analyzed for the 'Assessment' phase included 12,513 records, 50.4% concerning pain assessment, and 45% BMI. The nurse-patient ratio showed a significant direct association with the assessment of nutritional status ( = 0.032). The average weight DRG has a negative influence on pain and BMI assessment; the surgical units positively correlate with the compilation of nursing assessment (BMI and pain). The nursing process is an essential component for the continuous improvement in the quality of care. Nurses need to be accountable to improve their knowledge and skills in nursing documentation.
护理文件是护理质量的重要代理，护理评估中的质量指标可用于评估和改善医疗机构的护理质量。本研究旨在评估护理评估的完整性和准确性，分析计算机化护理记录中疼痛评估和营养状况（体重指数（BMI））的编制情况，以及四个变量如何影响其编制：护士与患者的比例、诊断相关组权重（DRG）、护士长的资历和病房类型（内科、外科或其他）。该观察性生态试点研究于 2018 年 9 月至 10 月在意大利一所三级教学医院进行。分析的“评估”阶段护理文件包括 12513 份记录，50.4%涉及疼痛评估，45%为 BMI。护士与患者的比例与营养状况评估呈显著正相关（ = 0.032）。平均 DRG 权重对疼痛和 BMI 评估有负面影响；外科病房与护理评估的编制呈正相关（BMI 和疼痛）。护理过程是持续提高护理质量的重要组成部分。护士需要负责提高护理文件记录方面的知识和技能。
