The article describes a study that compared the care observed with the records audit of patients admitted in an Italian hospital to undergo major abdominal surgery.
‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital
Article first published online: 20 APR 2010
© 2010 Blackwell Publishing Ltd
Journal of Clinical Nursing
Volume 19, Issue 11-12, pages 1544–1552, June 2010
How to Cite
De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R. and Matarese, M. (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, 19: 1544–1552. doi: 10.1111/j.1365-2702.2009.03012.x
- Issue published online: 13 MAY 2010
- Article first published online: 20 APR 2010
- Accepted for publication: 13 May 2009
- nursing assessment;
- nursing audit;
- nursing care;
- nursing records;
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.