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Acta Paulista de Enfermagem

On-line version ISSN 1982-0194


SANTOS, Silvana Sidney Costa et al. Development of a medical record for residents in a long-stay institution for the elderly. Acta paul. enferm. [online]. 2010, vol.23, n.6, pp.725-731. ISSN 1982-0194.

OBJECTIVE: To develop a medical record for residents in a long-stay institution for the elderly (LSIE) in the state of Rio Grande do Sul, in Brazil. METHODS: This was a research-action, conducted in a LSIE in the state of Rio Grande do Sul, in Brazil. Two researchers and 14 workers participated in the research (a nurse, a doctor, a nutritionist, a social worker, four nursing techniques, two caregivers and four administrators). It was utilized the group meetings with the participants, during the meetings were analyzed and discussed four themes: 1) purpose of the medical record; 2) composition of medical records; contributions of medical records to the LSIE; and 4) suggestions regarding medical records. RESULTS: To attend the contextual needs, the medical record of residents was developed jointly between researchers and the LSIE workers; the proposed medical record was implemented subsequently; it was composed of: personal data of the elderly; medical history; evolution of the multidisciplinary team; prescription and annotation of the nursing technique of care; systematization of nursing assistance; and, assessments (cognitive, affective, functional and social). CONCLUSIONS: The implemented medical record improved the systematization of care and contributed to improving the care for the elderly.

Keywords : Aged; Homes for the aged; Medical records.

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