[Nurses' patients' clinical record sheets; complying with legal requirements].
This article describes a 100 page long descriptive study based on nurses' clinical record sheets at three hospitals to discover the degree of compliance with legal requirements. Compilation of existing laws and a specialized bibliography provided the variables for this study. These were placed inside a data base which, once the information from each clinical record was introduced, made it possible to draw conclusions. Due to the socio-linguistic context, the language used and the linguistic interferences were also analyzed. This study showed there is a high rate of non-compliance with legal requirements. The impossibility to identify the professional who fills in each record sheet, low legibility the frequent use of abbreviations, initials, and symbols, crossed out illegible words, and unfinished record sheets have been noted in this study. The results of this study pose the possibility to make available in hospitals a list of legal requirements and of abbreviations, initials, and symbols employing a unified meaning.
Tarruella-Farré
Mireia
M
Universitat Autònoma de Barcelona. mireia@escola.creuroja.org
D009737:Nursing Records / Q000331:legislation & jurisprudence / Q000592:standards*