[The content and structure of nursing documentation in Careggi Hospital, Florence, 1998: results and perspectives].

This retrospective, observational study was performed to evaluate the structure and the content of the nursing documentation in the Azienda ospedaliera Careggi, Firenze in 1998. To this aim we review 1964 nursing records including both notes by turns and care plans. One-thousand-one-hundred-and-twenty-five records came from surgical and 839 from medical wards. From the selected records, every day of the hospital stay, including both the admission and the discharge, were evaluated, so that the studied days were a total of 18,683. Only 32% of the nursing records had a global assessment of patient situation on admission. A medical diagnosis was observed in 84% of the cases, but a nursing diagnosis was absent in over 99.5% of the charts. During stay most notes were related to medical treatment and visits. Nursing notes were lacking in 32% of turns, while "nothing to report" was recorded in another 15.5% of cases. A nursing care plan was present in a minority of records. A final evaluation of planned nursing interventions was reported in approximately 5% of the charts. Nursing care plans were updated during stay in less than one tenth of cases. Discharges notes were absent in slightly more than 80% of the cases. This survey confirms the importance of continuing education and supervision in nursing documentations, if a reliable source of nursing information has to be developed. Future nursing records should include only essential information, avoiding any overlap with medical charts.