INTRODUCTION:In literature it is reported that accurate nursing documentation improves patients’ outcomesbut nursing planning data is seldom available. The accuracy of nursing documentation in hospitals has beenassessed 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 havebeen conducted in Lombardy Region.AIM: the aim of this study is to assess the accuracy of nursing documentation in six hospitals. Accuracy indocumentation’s compilation was sought, as well as the three essential elements expected in the nursing deci-sion-making process: diagnoses, interventions and outcomes.METHOD: a multicentre retrospective observational study was conducted on a sample of 430 computerizedand paper-based nursing records in surgical and medical areas. D-Catch instrument was used to evaluatedocumentation’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 thedocumentation structure and the assessment are accurate, the presence of a nursing diagnosis, the accuracyof interventions and assessments and documentation’s clarity and legibility. RESULTS: 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 reachedan average score of 2.5, with significant differences between surgical and medical areas and between comput-erized and paper documentations. Interventions also showed significant differences between surgical andmedical areas, and between computerized and paper documentation, with an average score of 2.04. Theoutcomes received the lowest scores with an average of 1.75.CONCLUSIONS: 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 termi-nology that helps nurses to describe univocally the care process. The introduction of a standardized nursinglanguage and an integrated computerized medical record could help to improve the accuracy of the docu-mentation.
Bompan, A., Piazzalunga, M., Ausili, D., Alberio, M., Sironi, C., Di Mauro, S. (2020). Accuracy of hospital nursing documentation: a multi-center observational study. PROFESSIONI INFERMIERISTICHE, 73(2), 81-88.
Accuracy of hospital nursing documentation: a multi-center observational study
Ausili, D;Alberio, M;Sironi, C;Di Mauro, S
2020
Abstract
INTRODUCTION:In literature it is reported that accurate nursing documentation improves patients’ outcomesbut nursing planning data is seldom available. The accuracy of nursing documentation in hospitals has beenassessed 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 havebeen conducted in Lombardy Region.AIM: the aim of this study is to assess the accuracy of nursing documentation in six hospitals. Accuracy indocumentation’s compilation was sought, as well as the three essential elements expected in the nursing deci-sion-making process: diagnoses, interventions and outcomes.METHOD: a multicentre retrospective observational study was conducted on a sample of 430 computerizedand paper-based nursing records in surgical and medical areas. D-Catch instrument was used to evaluatedocumentation’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 thedocumentation structure and the assessment are accurate, the presence of a nursing diagnosis, the accuracyof interventions and assessments and documentation’s clarity and legibility. RESULTS: 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 reachedan average score of 2.5, with significant differences between surgical and medical areas and between comput-erized and paper documentations. Interventions also showed significant differences between surgical andmedical areas, and between computerized and paper documentation, with an average score of 2.04. Theoutcomes received the lowest scores with an average of 1.75.CONCLUSIONS: 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 termi-nology that helps nurses to describe univocally the care process. The introduction of a standardized nursinglanguage and an integrated computerized medical record could help to improve the accuracy of the docu-mentation.
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