Nursing documentation is an important proxy of the quality of care, and quality indicators in 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 the compilation of pain assessment and nutritional status (body mass index (BMI)) in computerized nursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis related group 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 an Italian 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-patient ratio 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 units positively correlate with the compilation of nursing assessment (BMI and pain). The nursing process is an essential component for the continuous improvement in the quality of care. Nurses need to be accountable to improve their knowledge and skills in nursing documentation.
Keywords: nursing assessment; nursing records; nutrition assessment; pain measurement; quality of healthcare.