Objective
To describe the documentary quality of two records related to patient safety in the operating room and to identify differences between information related to infection and hospitalization.
Methods
Comparative study based on two cross sections, conducted with 3,033 patients who had been hospitalized for more than 24 hours in an Orthopedics and Traumatology Center. Sociodemographic and clinical data, as well as information provided in forms were compared. Postoperative infection was identified as an adverse event.
Results
There was a significant correlation between hospitalization days and the total number of diagnoses collected (Pearson=0.328; p<0.001). When diagnoses and infections were grouped together, a significant value was found between closed fractures and infection (p=0.001).
Conclusion
Differences in the degree of completion were observed between the two records. There were no differences between adverse events.
Patient safety; Checklist; Operating room nursing; Nursing records; Surgical wound infection; Hospitalization