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Home > Vol 7, No 1 (2008) > Vituri
The records of nursing as indicators of the quality of care: a documentary study, exploratory and descriptive-retrospective
Os registros de enfermagem como indicadores da qualidade do cuidado: um estudo documental, descritivo-exploratório e retrospectivo.
Vituri, Dagmar Willamowius1, Matsuda, Laura Misue2.
1. Assessoria de Controle da Qualidade da Assistência de Enfermagem, Hospital Universitário Regional do Norte do Paraná, PR, Brasil; [e-mail] ; 2. Departamento de Enfermagem, Universidade Estadual de Maringá, PR, Brasil;[e-mail] . ABSTRACT: From the practical professional, many fidgets are excited in reason to failures detected in the nursing records. This study is intended to support discussions and meditation on this issue, aiming at the promotion of quality care. The purpose is to analyze the 2003-2006 nursing records quality evaluation reports accomplished by the nursing team of a medical surgeon unit of a public university hospital. It is a retrospective, descriptive-exploratory, and documentary study. The results had pointed that, regarding the standard of 80%, the item with the lowest percentage of positivity had been those relative to whether there were notes to indicate who carried through the care (nurse, technician or nurse aid); to whether there were notes on aspect and evolution of skin wounds and whether the prescribed treatment was countersigned, circulated and. It is concluded that the investigated service needs invest in the qualification of the team with regard to proper documentation of nursing care through continuous and permanent training programs as well as restore the role of the nurse as team leader, so that he can raise consciousness as to the importance and the correct and sufficient observance of the written records in the care process.
Keywords: Records, Nursing; Quality of Healthcare; Quality Indicators, Healthcare;Audit, Nursing;Standards
RESUMO: A partir da prática profissional,