Nursing documentation at the Bambino gesù children's hospital

IntroductionDuring the last ten years new laws have been passed which concern the nursing profession, both in training and education. Nurses now have all the tools necessary to develop nursing care based on customized nursing services. This will lead to activities planning in the nursing sector with autonomy as regards decision making and scientific methodology.ObjectiveTo adopt a healthcare model which is customisation-oriented and to develop a joint tool for nursing documentation, meeting the Joint Commission International requirements.Materials and methodsAfter in-depth analysis of the situation by means of a questionnaire submitted to head nurses and after an intense training work aimed at encouraging cultural change, we implemented and worked out a documentation based on the conceptual model of nursing services proposed by Marisa Cantarelli.ResultsThe following issues have emerged: –Lack of homogeneity of the care model–Lack of homogeneity of the nursing documentation–Inadequate nursing report filling–Non-compliance with JCI standards–Resistance to changeConclusionsThis project also aims at: –being the starting point of a long journey that will probably only be completed in a few years’ time–being a motivating force for all nurses to work towards an improvement in the quality of care for all our little and “big” patients.