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‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital

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  • Maria Grazia De Marinis
  • Michela Piredda
  • Maria Chiara Pascarella
  • Bruno Vincenzi
  • Fiorenza Spiga
  • Daniela Tartaglini
  • Rosaria Alvaro
  • Maria Matarese

Abstract

Aims. 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. Background. 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. 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 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. Results. 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. Conclusions. 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. 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.

Suggested Citation

  • Maria Grazia De Marinis & Michela Piredda & Maria Chiara Pascarella & Bruno Vincenzi & Fiorenza Spiga & Daniela Tartaglini & Rosaria Alvaro & Maria Matarese, 2010. "‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital," Journal of Clinical Nursing, John Wiley & Sons, vol. 19(11‐12), pages 1544-1552, June.
  • Handle: RePEc:wly:jocnur:v:19:y:2010:i:11-12:p:1544-1552
    DOI: 10.1111/j.1365-2702.2009.03012.x
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    References listed on IDEAS

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    1. Febe Friberg & Anne‐Louise Bergh & Margret Lepp, 2006. "In search of details of patient teaching in nursing documentation – an analysis of patient records in a medical ward in Sweden," Journal of Clinical Nursing, John Wiley & Sons, vol. 15(12), pages 1550-1558, December.
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    1. Sandra Braaf & Robin Riley & Elizabeth Manias, 2015. "Failures in communication through documents and documentation across the perioperative pathway," Journal of Clinical Nursing, John Wiley & Sons, vol. 24(13-14), pages 1874-1884, July.
    2. Kjellaug K. Myklebust & Stål Bjørkly & Målfrid Råheim, 2018. "Nursing documentation in inpatient psychiatry: The relevance of nurse–patient interactions in progress notes—A focus group study with mental health staff," Journal of Clinical Nursing, John Wiley & Sons, vol. 27(3-4), pages 611-622, February.
    3. Linda Høgsnes & Ella Danielson & Karl‐Gustaf Norbergh & Christina Melin‐Johansson, 2016. "Healthcare professionals' documentation in nursing homes when caring for patients with dementia in end of life – a retrospective records review," Journal of Clinical Nursing, John Wiley & Sons, vol. 25(11-12), pages 1663-1673, June.
    4. Gitte Bunkenborg & Lars Smith‐Hansen & Ingrid Poulsen, 2019. "Implementing mandatory early warning scoring impacts nurses’ practice of documenting free text notes," Journal of Clinical Nursing, John Wiley & Sons, vol. 28(15-16), pages 2990-3000, August.
    5. Gabriella Facchinetti & Andrea Ianni & Michela Piredda & Anna Marchetti & Daniela D’Angelo & Ivziku Dhurata & Maria Matarese & Maria Grazia De Marinis, 2019. "Discharge of older patients with chronic diseases: What nurses do and what they record. An observational study," Journal of Clinical Nursing, John Wiley & Sons, vol. 28(9-10), pages 1719-1727, May.

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