Introduction: Nursing profession requires that the specificity of one’s own knowledge to be shared through the use of efficient measurement 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 the Company Directives, highlighting the level of accuracy in the formulation of the nursing diagnosis. Materials and Methods: 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 was made to conduct a grading of the diagnostic terms and to examine the completeness, linguistic appropriateness and accuracy of the diagnoses made, by subjecting the data to descriptive statistical analysis. The standardised language referred to is NANDA-I. Results: “Risk of infection related to possible invasion of microorganism 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.
Introduzione: La professione infermieristica richiede che la specificità delle proprie conoscenze venga condivisa attraverso l’utilizzo di efficienti strumenti di misurazione, in grado di valutare in maniera peculiare i risultati degli interventi sanitari. Risulta quindi necessario che la documentazione venga prodotta utilizzando un linguaggio universale e standardizzato. L’obiettivo dello studio è di identificare le eventuali differenze e incongruenze tra il linguaggio utilizzato nella pratica quotidiana e la tassonomia di riferimento indicato dalle Direttive Aziendali, evidenziando il livello di accuratezza nella formulazione della diagnosi infermieristica. Materiali e Metodi: Confronto (cross mapping) delle diagnosi infermieristiche formulate in UOGI dell’AOU “Policlinico Umberto I” di Roma con quelle definite dalla tassonomia NANDA-I. L’analisi e la raccolta dei dati è stata effettuata nell’anno 2015 attraverso uno studio di coorte retrospettivo. Il campione preso in esame è di 99 cartelle cliniche e 97 diagnosi infermieristiche. Facendo riferimento al D-Catch, si è tentato di condurre un grading dei termini diagnostici ed esaminare la completezza, l’appropriatezza linguistica, nonché l’accuratezza delle diagnosi formulate, sottoponendo i dati ad analisi statistica descrittiva. Il linguaggio standardizzato a cui si è fatto riferimento è il NANDA-I. Risultati: “Rischio di infezione correlato a sede di possibile invasione di microrganismo secondaria a intervento chirurgico”, “Rischio di caduta correlato a storia di incidenti”, “Sindrome da immobilizzazione” sono le diagnosi che hanno perfettamente risposto ad un full-match e corrispondono al 9,4% del totale, mentre il 38,1% è stato identificato con un close match. Discussione: L’utilizzo di risorse quali un vocabolario standardizzato e concetti diagnostici pre-strutturati possono rendere la documentazione infermieristica sistematica, meno ridondante e in grado di tracciare perfettamente il processo assistenziale. Condurre uno studio che permetta di confrontare il linguaggio adottato con la tassonomia di riferimento consente di individuare le lacune presenti e mettere in atto nuove pratiche volte al miglioramento dell’outcome, promuovendo il corretto passaggio di informazioni.
L'accuratezza delle diagnosi infermieristiche: crossmapping in un'unità operativa a gestione infermieristica
Giannetta, Noemi;
2019-01-01
Abstract
Introduction: Nursing profession requires that the specificity of one’s own knowledge to be shared through the use of efficient measurement 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 the Company Directives, highlighting the level of accuracy in the formulation of the nursing diagnosis. Materials and Methods: 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 was made to conduct a grading of the diagnostic terms and to examine the completeness, linguistic appropriateness and accuracy of the diagnoses made, by subjecting the data to descriptive statistical analysis. The standardised language referred to is NANDA-I. Results: “Risk of infection related to possible invasion of microorganism 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.
