Analysis of records by nursing technicians and nurses in medical records

this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records.

Results:

the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses’ records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%.

Conclusions:

the study showed that nursing professionals perform their records incompletely and often do not document the care provided.

Descriptors:
Nursing; Communication; Nursing records; Patient safety; Health Services Research

Variable		Nursing technician (n = 345)		Nurse (n = 56)
Variable		n	%	n	%
Presence of date	Yes	331	95.9	52	92.8
	No	14	4.1	04	7.2
Presence of time	Yes	81	23.4	25	44.6
	No	264	76.6	31	55.4
Use of legible handwriting	Yes	186	53.7	46	82.1
	No	159	45.3	10	17.9
Registration without any erasure	Yes	264	76.3	55	98.2
	No	87	25.7	01	1.8
Use of abbreviations and standardized acronyms	Yes	290	83.8	51	89.1
Use of abbreviations and standardized acronyms	No	55	15.2	05	8.9

Variable			Nursing technician (n = 18)		Nurse (n = 25)
Variable			n	%	n	%
Patient 's origin		Yes	03	16.6	05	20.0
Patient 's origin		No	15	83.4	20	80.0
Identification of the companion		Yes	01	5.6	02	08.0
Identification of the companion		No	17	94.4	23	92.0
Arrival conditions		Yes	02	11.1	04	16.0
Arrival conditions		No	16	88.9	21	84.0
Concomitant diseases		Yes	06	33.3	06	24.0
Concomitant diseases		No	12	66.7	19	76.0
Life Habits		Yes	03	16.6	01	04.0
Life Habits		No	15	83.4	24	96.0
Presence of allergies		Yes	03	16.6	01	04.0
Presence of allergies		No	15	83.4	24	96.0
Medication use	Type	Yes	03	16.6	03	12.0
	Type	No	15	83.4	22	88.0
	Dosage	Yes	03	16.6	03	12.0
	Dosage	No	15	83.4	22	88.0
	Frequency	Yes	03	16.6	03	12.0
	Frequency	No	15	83.4	22	88.0

Variable		Nursing technician (n = 345)		Nurse (n = 56)
Variable		n	%	n	%
Name	Yes	142	41.1	49	87.5
Name	No	223	58.9	07	12.5
Professional category	Yes	42	12.1	53	94.6
Professional category	No	303	87.9	03	05.4
COREN Number	Yes	73	21.2	50	89.2
COREN Number	No	272	78.8	06	10.8

Variable		Nursing technician (n = 345)		Nurse (n = 56)
Variable		n	%	n	%
Level of consciousness	Yes	312	90.4	39	69.6
Level of consciousness	No	33	09.6	17	30.4
Mood	Yes	79	22.8	20	35.7
Mood	No	266	77.2	36	64.3
Personal hygiene	Yes	139	40.2	17	30.3
Personal hygiene	No	206	59.8	39	69.7
Attitude	Yes	65	18.8	17	30.3
Attitude	No	280	81.2	39	69.7
Skin coloration	Yes	71	20.5	07	12.5
Skin coloration	No	274	79.5	49	87.5
Nutritional status	Yes	113	32.7	22	39.2
Nutritional status	No	232	67.3	34	60.8
Locomotion	Yes	59	17.1	12	31.5
Locomotion	No	286	82.9	26	68.5
Type of excretions	Yes	170	49.2	21	37.5
Type of excretions	No	175	50.8	35	62.5
Consistency of excretions	Yes	39	11.3	10	17.8
Consistency of excretions	No	306	88.7	46	82.2
Odor of excretions	Yes	58	16.8	09	16.0
Odor of excretions	No	287	83.2	47	84.0
Coloring of excretions	Yes	47	13.6	10	17.8
Coloring of excretions	No	298	86.4	46	82.2
Device usage	Yes	278	80.5	31	55.3
Device usage	No	67	19.5	25	44.7
Patient complaints	Yes	137	39.7	22	39.2
Instructions for the patient/companion	Yes	38	11.0	09	16.0
Instructions for the patient/companion	No	307	89.0	47	84.0
Care and procedures performed	Yes	253	73.3	40	71.4
Care and procedures performed	No	92	26.7	16	28.6
Procedures and intercurrent event	Yes	163	50.9	31	55.3
Procedures and intercurrent event	No	157	49.1	25	44.7

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Corresponding Author: Flávia Barreto Tavares Chiavone flavia_tavares@hotmail.com