P104 | The appropriate recording of nursing procedures in an Italian Emergency Department: results of a nursing audit

A. Montini¹, G. Franceschini², M. Porfiri³ | ¹AST Ascoli Piceno, Anestesia e Rianimazione, ²Ars Marche, Ancona, ³Ast Ascoli Piceno, Risorse Umane, Italy

Premises and Purpose of the study: Nursing documentation makes the care process observable and measurable. In the Emergency Department (ED) the appropriate compilation of nursing documentation is hampered by the intense rhythms related to the high intensity of care. This study aimed to analyze the practice of registration of the care activities in the nursing documentation, in an ED of a second level hospital in the Marche region (IT), also defining improvement actions.
Materials and Methods: A Nursing Audit conducted in 2019, involved a sample of nurses of the ED of an Italian hospital. Based on the international literature and on a benchmarking activity involving some Italian EDs, a panel of recommended items related to the nursing documentation has been identified and a data collection form has been created.
Results: N. 403 data collection forms were collected, in relation to patients assisted in the emergency room or in the Short Intensive Observation of the ED. Results showed that nursing records only in 10% of cases reported the care activities’ procedures. The registration of care activities, when conducted, was incomplete in 93% of cases. The inappropriateness and the incompleteness of the recorded data were correlated with the clinical care complexity of the patients.
Conclusions: This study revealed that recording of nursing documentation in the ED involved in the present study is not correct, neither complete. Implementing digitalization strategies could overcome this relevant issue, improving the quality and the efficiency of the nursing care process.