Aims. The aim of this study is to evaluate the consistency between the care given to patients and that documented, by comparingcare observations with nursing records and describing which interventions were reported and which were omitted.Background. Assumptions have been made about the relationship between documentation and care actually delivered, but thereis insufficient evidence on the relationship between the actual care given and its recording.Design. Observational study of the care given, completed by interviews and retrospective survey of records.Methods. Structured observation during day shifts in the first six days of admission of pre and postsurgical care provided to 21consecutive patients undergoing major abdominal surgery and audit of their nursing records. Each observation was completedby short interviews to nurses to ensure observations validity.Results. Only 40% of nursing activities observed were included in the nursing records (37% of the assessments and 45% of theinterventions). This indicated that nurses carry out more activities than they report. Consistency between performed andrecorded care decreased significantly during the days when a higher number of activities were performed. Consistency betweenrecording and observation of assessment activities was 38% for physical needs and 0% for educational needs. Consistency washigher for the assessments of physical signs/symptoms and risk factors for complications compared to the assessment of basicneeds and pain. Consistency was 47% for technical interventions and 3% for educational activities.Conclusions. Nursing records were not found to be an adequate tool for quality care evaluation, because they did not include allthe caring activities that the nurses had carried out.Relevance to clinical practice. 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.
“If it is not recorded, it has not been done!”? Consistency between nursing records and observed nursing care in an Italian hospital.
DE MARINIS MG;PIREDDA M;VINCENZI B;TARTAGLINI D;MATARESE M
2010-01-01
Abstract
Aims. The aim of this study is to evaluate the consistency between the care given to patients and that documented, by comparingcare observations with nursing records and describing which interventions were reported and which were omitted.Background. Assumptions have been made about the relationship between documentation and care actually delivered, but thereis insufficient evidence on the relationship between the actual care given and its recording.Design. Observational study of the care given, completed by interviews and retrospective survey of records.Methods. Structured observation during day shifts in the first six days of admission of pre and postsurgical care provided to 21consecutive patients undergoing major abdominal surgery and audit of their nursing records. Each observation was completedby short interviews to nurses to ensure observations validity.Results. Only 40% of nursing activities observed were included in the nursing records (37% of the assessments and 45% of theinterventions). This indicated that nurses carry out more activities than they report. Consistency between performed andrecorded care decreased significantly during the days when a higher number of activities were performed. Consistency betweenrecording and observation of assessment activities was 38% for physical needs and 0% for educational needs. Consistency washigher for the assessments of physical signs/symptoms and risk factors for complications compared to the assessment of basicneeds and pain. Consistency was 47% for technical interventions and 3% for educational activities.Conclusions. Nursing records were not found to be an adequate tool for quality care evaluation, because they did not include allthe caring activities that the nurses had carried out.Relevance to clinical practice. 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.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
