[The evaluation of the quality of nursing records: a comparison between departments that use the card, the nursing chart and the traditional order. The Nursing Research Group of Monza].
Quality of symptoms registration on three different models of nursing records was reviewed to assess whether a more patient oriented nursing record could influence completedness and precision of symptoms registration. A group of nurses set minimum criteria for five symptoms (pain, emesis, diarrhea, fever and constipation), according to the nursing process: description of written registrations of 517 symptoms were assessed. No differences appear to exist among the three different models of records, except for evaluation of the results of the interventions, more reported in the patient oriented nursing records.
D005069:Evaluation Studies as Topic; D005568:Forms and Records Control / Q000592:standards; D007558:Italy; D008501:Medical Records, Problem-Oriented / Q000592:standards; D009737:Nursing Records / Q000592:standards*
Valutazione della qualità delle registrazioni infermieristiche: confronto tra reparti che utilizzano la cartella, la scheda infermieristica e la consegna tradizionale. Gruppo di Ricerca Infermieristica di Monza.