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Online ISSN 1827-1707
ADVERSE EVENTS PREVENTION AND CONTROL STRATEGIES
Schirru M. A. 1, Grivet V. 2
1 Servizio Infermieristico, A.S.L. 2 Torino
2 Divisione di Nefrologia e Dialisi, A.S.L. 2 Torino
A myriad of information is generated during the delivery of health care, so that objectives need to be defined in order to create a reporting system that contains all pertinent information. Since the content of the nursing report in general and the nurse’s chart in particular is not legally defined, it must be derived from professional practice as outlined under the provisions of Law 42/1999 and Law 251/2000. As nursing skills and professional duties have been redefined, the nursing report has acquired legal, managerial and informative dimensions. In this article, the legal implications of the nursing report are outlined, given that the report is compiled by health care professionals in their public line of duty. The requirements a nursing report should meet are also described. Within the scope of the legal aspects of nursing care, the strictly professional characteristics are examined with a view to define, analyze and review the information tools used in the delivery of health care. In its managerial dimension, the nursing report may permit a series of evaluations that are then analyzed in detail. The nurse’s chart is a widespread tool and is considered an integral part of medical documentation. Hence, it should be compiled according to standard rules to protect both the patient and the health worker. As it is the nurse who is responsible for evaluating the patient’s needs and planning treatment, adequate models and methods of report compilation should be developed.