Quality of Care: Ecological Study for the Evaluation of Completeness and Accuracy in Nursing Assessment

Nursing documentation is an important proxy of the quality of care, and quality indicatorsin nursing assessment can be used to assess and improve the quality of care in health care institutions.The study aims to evaluate the completeness and the accuracy of nursing assessment, analyzing thecompilation of pain assessment and nutritional status (body mass index (BMI)) in computerizednursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis relatedgroup weight (DRG), seniority of charge nurse, and type of ward (medical, surgical or other).The observational ecological pilot study was conducted between September and October 2018 in anItalian Tertiary-Level Teaching Hospital. The nursing documentation analyzed for the ‘Assessment’phase included 12,513 records, 50.4% concerning pain assessment, and 45% BMI. The nurse–patientratio showed a significant direct association with the assessment of nutritional status (p = 0.032).The average weight DRG has a negative influence on pain and BMI assessment; the surgical unitspositively correlate with the compilation of nursing assessment (BMI and pain). The nursing processis an essential component for the continuous improvement in the quality of care. Nurses need to beaccountable to improve their knowledge and skills in nursing documentation.