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Online ISSN 1827-1677
Milano M. M., Valleris E., Iorio M.
Every professional activity refers to values, uses knowledge and makes use of instruments. The nurding profession is based on the concept of man and his relationship to health: its structure reflects the special way in which the service rendered by nurses to society is perceived and legitimated. Their professionalism is also expressed by the formulation of instruments suited to working requirements in the various contexts: nursing activities are based on interpersonal relations and on communication. Therefore, an essential working tool is the transmission of information obtained from dialogue, observation and execution. The nursing record responds well to the needs of nurses, allowing them to work in compliance with the theoretical principles and references on which their profession is based in recept of the patient's wishes. Its existence has recently become highly topical following the evolution of national regulations that sanction for all professions the obligations of respecting privacy asnd the protection of personal data, thereby reinforcing the obligations expressed by the civil and criminal codes. At an ethical level, nursing information is subject to professional secrecy and represents a specific duty of the nurse as part of health education, prevention, treatment and rehabilitation. The ethical aspects of nursing communication and information, the basal elements for interpersonal relations, refer to both the patient's rights and the duties of the health personnel. The use of nursing records, a tool for communication between professionals and for information management, is subject to compliance with the ethical and deontological regulations that govern professional conduct. The nursing record is also important in the light of the abolition of the task list, the first stage in the definition of the professional autonomy of nurses, and it therefore represents an instrument of emancipation for the entire category. This study analyses the nursing record in the light of the most recent legislation and on the basis of ethical principles underlying nursing activities. Starting from an analysis of the historical foundations, it examines the current reality and nurses' opinions regarding these instruments. The ultimate aim of the study was to draw up guidelines to serve as a working reference for those who deal everyday with user requirements and statutory dispositions. To do so, it was first of all necessary to compare the nursing record with other aspects of the health profession that are also of juridical interest, namely professional secrecy, informed consent and the protection of sensitive data. The authors report the results of a vast survey made of the health system covering the health operators in the city. The study ends with a structured proposal for a standard model of the nursing record.