Acta Paulista de Enfermagem
Print version ISSN 0103-2100
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 0103-2100. http://dx.doi.org/10.1590/S0103-21002010000600002.
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.