This is a retrospective longitudinal study conducted in a Specialized Unit in the interior of Brazil. It aimed at verifying differences in nursing records with regard to how to document the care provided to patients in three periods related to the implementation of the Nursing process. Data were collected from 20% of the records of patients aged over 15 years who were randomly selected according to proportional distribution. Such data were fully transcribed in an instrument constructed for this purpose and classified according to the proposals of the referential. The Binomial Test was used for analysis with a significance level of 0.05%. The results showed a tendency to improvement of the records as to writing intellection and complete description of the signs/symptoms in the second period. It was concluded that there was a difference between the initial and the pre-implementation periods, which expresses the need to review the way the Nursing Process must be developed as a responsibility of the whole nursing team.
nursing records; nursing assessment; nursing team
