Introduction: Nursing profession requires that the specificity of one’s own knowledge to be shared through the use of efficientmeasurement tools, able to assess, in a particular way, health interventions results. Therefore, it is necessary for the documentation to be produced using a universal and standardised language. The aim of the study is to identify any differences and inconsistencies between the language used in everyday practice and the referred taxonomy indicated by theCompanyDirectives, highlighting the level of accuracy in the formulation of the nursing diagnosis. The Cross-mapping of nursing diagnoses formulated in the UOGI of the AOU “Policlinico Umberto I” of Rome, were collected in 2015 through a retrospective cohort study. The sample taken is 99 medical records and 97 nursing diagnoses. Referring to D-Catch, an attempt wasmade to conduct a grading of the diagnostic terms and to examine the completeness, linguistic appropriateness and accuracy of the diagnosesmade, by subjecting the data to descriptive statistical analysis. The standardised language referred to is NANDA-I. Results: "Risk of infection related to possible invasion ofmicroorganism secondary to surgery", "Risk of falling related to accident history", "Immobilization syndrome" are the diagnoses that have perfectly responded to a full-match and correspond to 9.4% of the total, while 38.1%was identified with a close match. Discussion: Using resources such as a standardised vocabulary and pre-structured diagnostic concepts can make nursing documentation systematic, less redundant and able to perfectly outline the assistance process. Conducting a study to compare the language adopted with the referred taxonomy allows the identification of existing gaps and the implementation of new practices aimed at improving the outcome, promoting the correct flow of information.
L’accuratezza delle diagnosi infermieristiche: Cross Mapping in un’unità operativa a gestione infermieristica
Cianciulli, Angelo;
2019
Abstract
Introduction: Nursing profession requires that the specificity of one’s own knowledge to be shared through the use of efficientmeasurement tools, able to assess, in a particular way, health interventions results. Therefore, it is necessary for the documentation to be produced using a universal and standardised language. The aim of the study is to identify any differences and inconsistencies between the language used in everyday practice and the referred taxonomy indicated by theCompanyDirectives, highlighting the level of accuracy in the formulation of the nursing diagnosis. The Cross-mapping of nursing diagnoses formulated in the UOGI of the AOU “Policlinico Umberto I” of Rome, were collected in 2015 through a retrospective cohort study. The sample taken is 99 medical records and 97 nursing diagnoses. Referring to D-Catch, an attempt wasmade to conduct a grading of the diagnostic terms and to examine the completeness, linguistic appropriateness and accuracy of the diagnosesmade, by subjecting the data to descriptive statistical analysis. The standardised language referred to is NANDA-I. Results: "Risk of infection related to possible invasion ofmicroorganism secondary to surgery", "Risk of falling related to accident history", "Immobilization syndrome" are the diagnoses that have perfectly responded to a full-match and correspond to 9.4% of the total, while 38.1%was identified with a close match. Discussion: Using resources such as a standardised vocabulary and pre-structured diagnostic concepts can make nursing documentation systematic, less redundant and able to perfectly outline the assistance process. Conducting a study to compare the language adopted with the referred taxonomy allows the identification of existing gaps and the implementation of new practices aimed at improving the outcome, promoting the correct flow of information.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
