Investigation of “Nursing Records” in Basic Nursing Education

Abstract

With the aim of ascertaining the real conditions regarding education concerning nursing records, we conducted research on textbooks and utilized a questionnaire survey given to nursing teachers. Thirty-seven textbooks for the training of registered nurses and six for the training of licensed practical nurses were reviewed. The analysis revealed that nursing records were addressed mainly in basic nursing and often placed in “nursing process.” The definition, components, and categorization of nursing records varied. A questionnaire on the teaching of nursing records was answered by 2,604 full-time teachers in schools of nursing for registered nurse and 136 full-time teachers at training schools for practical nurse across the nation. The survey results showed that classes on basic nursing （including management） or basic nursing techniques often addressed nursing records, usually dealing with its purposes, significance, recording methods, and points to keep in mind, but rarely covering legal regulations or the operation/management of nursing records. Practical training did not include actual recording practice and records were accessed by permission. These findings revealed the diversity of the definition of nursing records and educational content as well as restrictions in hands-on training. The study showed the necessity of the careful selection of basic learning content, harmonization with guidelines used in clinical settings, and educational improvement including practical training that conforms to nursing practices.