'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

Volumn 19, Issue 11-12, 2010, Pages 1544-1552

  De Marinis, Maria Grazia ^a   Piredda, Michela ^a   Pascarella, Maria Chiara ^a   Vincenzi, Bruno ^a   Spiga, Fiorenza ^a   Tartaglini, Daniela ^a   Alvaro, Rosaria ^b   Matarese, Maria ^a  

^a UNIVERSITY CAMPUS BIO MEDICO   (Italy)

^b UNIVERSITY OF ROME TOR VERGATA   (Italy)

Author keywords

Interview; Nursing assessment; Nursing audit; Nursing care; Nursing records; Observation

Indexed keywords

ADULT; ARTICLE; FEMALE; HUMAN; ITALY; MALE; MEDICAL RECORD; NURSING CARE; NURSING STAFF; RETROSPECTIVE STUDY;

ADULT; FEMALE; HUMANS; ITALY; MALE; NURSING CARE; NURSING RECORDS; NURSING STAFF, HOSPITAL; RETROSPECTIVE STUDIES;

EID: 77955965856     PISSN: 09621067     EISSN: 13652702     Source Type: Journal    
DOI: 10.1111/j.1365-2702.2009.03012.x     Document Type: Article

References (51)

1. Adamsen L, Tewes M. Discrepancy between patients perspectives, staff's documentation and reflections on basic nursing care. Scandinavian Journal of Caring Sciences 2000, 14:120-129.
2. Allen D. Record-keeping and routine practice: the view from the wards. Journal of Advanced Nursing 1998, 27:1223-1230.
3. Alloni R, Gianotti L. L'Assistenza al Paziente Chirurgico 2003, Euroma, Roma, Italy
4. Bradshaw S. Phaneuf's nursing audit. 'Nursing Quality Measurement. Quality AssuranceMethods for Peer Review' 1987, 45-52. Pearson A. ed, John Wiley & Sons, Christer, pp
5. Briggs M, Dean K. A qualitative analysis of the nursing documentation of post-operative pain management. Journal of Clinical Nursing 1998, 7:155-163.
6. Casey FS. Documenting patient education: a literature review. Journal of Continuing Education in Nursing 1995, 26:257-260.
7. Chaboyer W, Wallis M, Duffield C, Courtney M, Seaton P, Holzhauser K, Schluter J, Bost N. A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: an observational study. International Journal of Nursing Studies 2008, 45:1274-1284.
8. Coyne ML, Smith JFH, Stein D, Hieser MJ, Hoover L. Describing pain management documentation. Medsurg Nursing 1998, 7:45-51.
9. Currell R, Urquhart C. Nursing record systems: effects on nursing practice and health care outcomes. Cochrane Database of Systematic Reviews 2003, 3:CD002099.
10. Davis BD, Billings JR, Ryland RK. Evaluation of nursing process documentation. Journal of Advanced Nursing 1994, 19:960-968.
11. De la Cuesta C. The nursing process from development to implementation. Journal of Advanced Nursing 1983, 8:365-371.
12. Dennis KE, Sweeney PM, Macdonald LP, Morse NA. Point of care technology: impact on people and paperwork. Nursing Economics 1993, 11:229-237.
13. Dimond B. Prescription and medication records. The British Journal of Nursing 2005, 14:1203-1205.
14. Donabedian A. The quality of care. How can it be assessed? Journal of the American Medical Association 1988, 260:1743-1760.
15. Ehnfors M, Smedby B. Nursing care as documented in patient records. Scandinavian Journal of Caring Sciences 1993, 7:209-220.
16. Ehrenberg A, Ehnfors M. The accuracy of patient records in Swedish nursing-homes: congruence of record content and nurses' and patients' descriptions. Scandinavian Journal of Caring Sciences 2001, 15:303-310.
17. Ehrenberg A, Ehnfors M, Smedby B. Auditing nursing content in patient records. Scandinavian Journal of Caring Sciences 2001, 15:133-141.
18. Friberg F, Bergh AL, Lepp M. In search of details of patient teaching in nursing documentation - an analysis of patient records in a medical ward in Sweden. Journal of Clinical Nursing 2006, 15:1550-1558.
19. Griffiths J, Hutchings W. The wider implications of an audit of care plan documentation. Journal of Clinical Nursing 1999, 8:57-65.
20. Griffiths P, Debbage S, Smith A. A comprehensive audit of nursing record keeping practice. The British Journal of Nursing 2007, 16:1324-1327.
21. Gryfinsky JJ, Lampe SS. Implementing focus charting: process and critique. Clinical Nurse Specialist 1990, 4:200-205.
22. Gunningberg L, Idvall E. The quality of postoperative pain management from the perspectives of patients, nurses and patient records. Journal of Nursing Management 2007, 15:756-766.
23. Hakes B, Whittington J. Assessing the impact of an electronic medical record on nurse documentation time. CIN: Computers, Informatics, Nursing 2008, 26:234-241.
24. Hale CA, Thomas LH, Bond S, Todd C. The nursing record as a research tool to identify nursing interventions. Journal of Clinical Nursing 1997, 6:207-214.
25. Hansebo G, Kihlgren M, Ljunggren G. Review of nursing documentation in nursing home wards - changes after intervention for individualized care. Journal of Advanced Nursing 1999, 29:1462-1473.
26. Harvey G. An evaluation of approaches to assessing the quality of nursing care using (predetermined) quality assurance tools. Journal of Advanced Nursing 1991, 16:277-286.
27. Idvall E, Ehrenberg A. Nursing documentation of postoperative pain management. Journal of Clinical Nursing 2002, 11:734-742.
28. Jones A. Admitting hospital patients: a qualitative study of an everyday nursing task. Nursing Inquiry 2007, 14:212-223.
29. Karkkainen O, Eriksson K. Evaluation of patient record as part of developing a nursing care classification. Journal of Clinical Nursing 2003, 12:198-205.
30. Kirrane C. An audit of care planning on a neurology unit. Nursing Standard 2001, 15:36-39.
31. Lamond D. The information content of the nurse change of shift report: a comparative study. Journal of Advanced Nursing 2000, 31:794-804.
32. Lundgren A, Jorfeldt L, Ek AC. The care and handling of peripheral intravenous cannulae on 60 surgery and internal medicine patients: an observation study. Journal of Advanced Nursing 1993, 18:963-971.
33. Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. The Australian Journal of Physiotherapy 2005, 51:151-159.
34. Marcum J, Ridenour M, Shaff G, Hammons M, Taylor M. A study of professional nurses' perceptions of patient education. Journal of Continuing Education in Nursing 2002, 33:112-118.
35. Martin A, Hinds C, Felix M. Documentation practices of nurses in long term care. Journal of Clinical Nursing 1998, 8:345-352.
36. McElroy A, Corben V, McLeish K. Developing care plan documentation: an action research project. Journal of Nursing Management 1995, 3:193-199.
37. McWay D. Legal Aspects of Health Information Management 2002, 2nd edn, Thomson Delmar Learning, New York
38. http://213.203.141.50/professione/ArchivioLeggi/Files/179/DM140994n739.pdf, Ministerial Decree, (Decreto Ministeriale) 14/09/1994, n. 739. Regolamento concernente l'individuazione della figura e del relativo profilo professionale dell'infermiere. Gazzetta Ufficiale 9 gennaio 1995, n. 6. Available at: (accessed 4 July 2007)
39. Moloney R, Maggs C. A systematic review of the relationships between written manual nursing care planning, record keeping and patient outcomes. Journal of Advanced Nursing 1999, 30:51-57.
40. Nielsen KG, Holte K, Kehlet H. Effects of posture on postoperative pulmonary function. Acta Anaesthesiologica Scandinavica 2003, 47:270-275.
41. Nordström G, Gardulf A. Nursing documentation in patient records. Scandinavian Journal of Caring Sciences 1996, 10:27-33.
42. Guidelines for Records and Record Keeping 2005, Nursing and Midwifery Council, NMC, London
43. Openshaw S. Literature review: measurement of adequate care. International Journal of Nursing Studies 1984, 21:295-304.
44. Palese A, Garcìa Cabarcas R, Dotti R, Riboli O. Documentazione scritta (consegne e piani di assistenza). Assistenza Infermieristica e Ricerca 2006, 25:109-114.
45. Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: does care change when observed? Journal of the American Medical Directors Association 2006, 7:541-544.
46. Sparrow S, Robinson J. The use and limitations of Phaneuf's nursing audit. Journal of Advanced Nursing 1992, 17:1479-1488.
47. Tapp RA. Inhibitors and facilitators to documentation of nursing practice. Western Journal of Nursing Research 1990, 12:229-240.
48. Taylor H. Professional issues. An exploration of the factors that affect nurses' record keeping. The British Journal of Nursing 2003, 12:751-754.
49. Standards for Records and Record Keeping 1993, UKCC, United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London
50. Yura H, Walsh MB. The Nursing Process: Assessing, Planning, Implementing, Evaluating 1988, 5th edn, Appleton & Lange, New York
51. Zeitz K. Nursing observations during the first 24 hours after a surgical procedure: what do we do? Journal of Clinical Nursing 2005, 14:334-343.