[The use of nursing records in the Veneto region]

Use and quality of nursing records used in the Regione Veneto hospitals was evaluated. An open ended questionnaire was sent to the nurses managers of each hospital. The questionnaire asked some general information on the hospital (number of beds, number and qualification of nursing personnel) and nurses managers were asked to send a blank copy of the nursing records in use. 21 nurses managers answered, overall responsible for 28 hospitals. Nurses records are used in 78 wards over 412 (19.1%). The wards are different for specialty and characteristics. Apparently, the only factor associated with the implementation of nursing records is the number of beds, with a wider implementation of nursing records in smaller hospitals. No association was found with the level of qualification of the nursing personnel. 11 nursing records were received. The items to be compulsorily monitored were mostly physical needs (i.e. elimination, hygiene, nutrition, mobilization), with the exception of the two records used in the psychiatric wards, where data on the behaviour and reaction of the patient was available.