The nursing records are essential to generate benefits to individualized care planning, being data collection the first step of the Nursing Process. The goal of this study was the analyses of the records made by nurses during each physical patient examination of an critical care unit (CCU) and clinic unit (UIC). This work is a transverse and retrospective study, in which forms and records from public as well as private hospitals were analyzed. From all 69 records considered, it was observed that records with more quality and frequency were found into the CCU, whilst records from UIC were mostly about undercurrent developed by the patients. It was showed up a deficit in patient physical examination records, which complicates the individual assistance focused on real patient needs, since some important information are not recorded.
Forms and records control; Physical examination; Nursing records
