Aim: considering that the nursing record il the cucial instrument for the nursing process, with this thesis we wanted:
- to analyse how the nurses use the nursing record;
- to give back at the compilation of the nursing record the right importance.
Summary: I have analysed 1000 nursing records of the University General Hospital of Modena.
The analysis shows that the nurses have some difficulty to draw up documents. First, we can note how the personal data and the assessment are for the most part incomplete, causing an incomplete knowledge of the person at the moment of admission. Secondly, we can note how the nurses have a tendency to document what they have made instead of what they are going to make; in fact the data show that the diary is filled with greater frequency in comparison with the planning. However, we must remember that it is also thanks to the planning that the nurse of today isn't a simple executor of actions, but rather aware and responsible of the actions that he executes.
Conclusion: to deal with this matter it is necessary to boost the use of the whole nursing process in writing form and not only practice form; this is also important because, in a case of law dispute, as we say "dawn in black and white".
As for that it would be helpful:
- to promote an adequate formation to the nursing documentation;
- to get a law fron the State or guidelines from the College of nurses that binds the nurses to document their actions correctly;
- where it is possible, to implement the use of the computerized nursing record.
