title: 'If it is not recorded, it has not been done!'? consistency between nursing records and observed nursing care in an Italian hospital.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: University Campus Bio-Medico, 200-00128 Rome, Italy. m.demarinis@unicampus.it
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: De Marinis
authors.forename: Michela
authors.initials: M
authors.lastname: Piredda
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Pascarella
authors.forename: Bruno
authors.initials: B
authors.lastname: Vincenzi
authors.forename: Fiorenza
authors.initials: F
authors.lastname: Spiga
authors.forename: Daniela
authors.initials: D
authors.lastname: Tartaglini
authors.forename: Rosaria
authors.initials: R
authors.lastname: Alvaro
authors.forename: Maria
authors.initials: M
authors.lastname: Matarese
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D009732:Nursing Care; D009737:Nursing Records; D009741:Nursing Staff, Hospital; D012189:Retrospective Studies