Bompan Anna, Piazzalunga Martina, Ausili Davide, Alberio Massimo, Sironi Cecilia, Di Mauro Stefania
RN, MSc. Infermiera tutor ASST Sette laghi, c/o Corso di laurea in infermieristica sede di Varese, Università degli Studi dell'Insubria. Corrispondence:
RN, MSc. Infermiera ASST di Monza. Corrispondence:
Prof Inferm. 2020 Apr-Jun;73(2):81-88. doi: 10.7429/pi.2020.732081.
In literature it is reported that accurate nursing documentation improves patients' outcomes but nursing planning data is seldom available. The accuracy of nursing documentation in hospitals has been assessed in many healthcare settings through the detection of three key elements of nursing decision-making: diagnoses, interventions and outcomes. However, studies conducted in Italy are scant and none of them have been conducted in Lombardy Region.
the aim of this study is to assess the accuracy of nursing documentation in six hospitals. Accuracy in documentation's compilation was sought, as well as the three essential elements expected in the nursing decision-making process: diagnoses, interventions and outcomes.
a multicentre retrospective observational study was conducted on a sample of 430 computerized and paper-based nursing records in surgical and medical areas. D-Catch instrument was used to evaluate documentation's accuracy. This instrument is divided into six sections, with scores ranging from one to four: a higher score corresponds to a greater accuracy of the documentation. The six sections assess whether the documentation structure and the assessment are accurate, the presence of a nursing diagnosis, the accuracy of interventions and assessments and documentation's clarity and legibility.
it emerged that in the six hospitals there is a structured and personalized nursing documentation. From the 430 nursing documentations, a total of 623 nursing diagnoses were observed. Diagnoses reached an average score of 2.5, with significant differences between surgical and medical areas and between computerized and paper documentations. Interventions also showed significant differences between surgical and medical areas, and between computerized and paper documentation, with an average score of 2.04. The outcomes received the lowest scores with an average of 1.75.
the specific nursing data that would make the care process evident are hardly visible and, despite the nursing records of the six hospitals being oriented by a conceptual model, there is no shared terminology that helps nurses to describe univocally the care process. The introduction of a standardized nursing language and an integrated computerized medical record could help to improve the accuracy of the documentation.
文献报道准确的护理记录可改善患者预后，但护理计划数据却很少可得。通过检测护理决策的三个关键要素：诊断、干预措施和结果，在许多医疗环境中对医院护理记录的准确性进行了评估。然而，在意大利进行的研究很少，且没有一项研究是在伦巴第地区开展的。
本研究旨在评估六家医院护理记录的准确性。研究寻求记录编制的准确性，以及护理决策过程中预期的三个基本要素：诊断、干预措施和结果。
对手术和医疗领域的430份电子化和纸质护理记录样本进行了多中心回顾性观察研究。使用D-Catch工具评估记录的准确性。该工具分为六个部分，评分范围为1至4分：分数越高表明记录的准确性越高。这六个部分评估记录结构和评估是否准确、护理诊断的存在情况、干预措施和评估的准确性以及记录的清晰度和易读性。
结果显示，六家医院均有结构化且个性化的护理记录。在430份护理记录中，共观察到623个护理诊断。诊断的平均得分为2.5分，手术和医疗领域之间以及电子化和纸质记录之间存在显著差异。干预措施在手术和医疗领域之间以及电子化和纸质记录之间也显示出显著差异，平均得分为2.04分。结果得分最低，平均分为1.75分。
使护理过程清晰可见的具体护理数据很难看到，尽管六家医院的护理记录以概念模型为导向，但却没有有助于护士明确描述护理过程的通用术语。引入标准化护理语言和集成电子化病历可能有助于提高记录的准确性。
