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[The written nursing reports of the asylum "Paolo Pini" of Milan, from 1944 to 1947]
Marina Negri1, Vanna Marchesini2, Silvio De Valerio3
1Coordinatore Didattico Corso di laurea in Infermieristica Università degli Studi di Milano Ospedale Niguarda, Milano.
Introduction:
The work provides the analysis of the nursing reports written by the nursing staff on duty at the asylum "Paolo Pini" from 1944 to 1947.
Objective:
description of the nursing report evolution, analyses of the quantitative and qualitative matters. Study of the evolution of the records: enhancement of the description of the patient, integration between medical and nursing assistance, assumption of responsi- bility (for instance through the signature).
Methods:
A sampling of 355 medical records has been analysed. The nursing records have been identified according to the theoretical model of Marisa Cantarelli. They have been compared with the current standard reported in literature. If recognizable signatures were present, they have been checked in the archives of the Province of Milan.
Results:
219 records concerning nursing assistance have been selected. The record changed during the years assuming a definite structure, and became a pre printed form; its use spread in all the wards of the hospital. The record deals with nursing assistance needs, and improves during the years becoming more and more detailed and regular.
Conclusions:
During the analysed time frame, the nursing reports at "Paolo Pini" improve and become more exhaustive and regular; they prove to be part of the medical record, showing a good integration between doctors and nurses activities. The evolution of this tool confirms the need of highlighting and improving the assistance practice.