L’accuratezza delle diagnosi infermieristiche: Cross Mapping in un’unità operativa a gestione infermieristica

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 2019, Volume 3, Nr.1, pp. 1-26 L’accuratezza delle diagnosi infermieristiche: Cross Mapping in un’unità operativa a gestione infermieristica 5 taxonomy allows the identification of existing gaps and the implementation of new practices aimed at improving the outcome, promoting the correct flow of information.