[Nursing notes: what do they contribute to the quality of medical records?].
Treatment records are preferential tools in nursing care. Depending on the setting, its development has gained greater importance during the last thirty years. In the environment of an organization in charge of the computerization of patient files, an evaluation was conducted on the contents of the anamneses and daily observations of nurses. This study, concerning 110 medical records demonstrated the different facets in the methods of transcribing data from notes ensuing from observations, action, and evaluation. Alternatively, the impact of this procedure translates into concrete propositions by the medical teams, as well as exploring the benefits of charting the treatment records themselves.
Hôpitaux Universitaires de Genève (HUG).
Ronald
R
Müller
Anne-Claire
AC
Raë
Vincent
V
Dupont
Sandra
S
Merkli
Ingrid
I
Lang
D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009730:Nursing Assessment / Q000592:standards; D009731:Nursing Audit; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000592:standards*; D010347:Patient Care Planning / Q000592:standards; D017749:Total Quality Management