Acta Paulista de Enfermagem
Print version ISSN 0103-2100
FERNANDES, Ana Paula; VANCINI, Cássia Regina; COHRS, Frederico and MOREIRA, Rita Simone Lopes. Quality of nursing records related to cardiopulmonary resuscitation compared to the Utstein model. Acta paul. enferm. [online]. 2010, vol.23, n.6, pp. 757-763. ISSN 0103-2100. http://dx.doi.org/10.1590/S0103-21002010000600007.
OBJECTIVE: To assess the quality of nursing records related to cardiopulmonary resuscitation, comparing them to the validated Utstein protocol, in a university hospital. METHODS: Retrospective, exploratory and descriptive study, with quantitative approach, performed by means of consultation records of patients that suffered cardiorespiratory arrest (CRA) followed by death. The data collection was carried out in the period of May 1st to June 30th, in 2009. RESULTS: Of the 144 medical records surveyed, 74 were dismissed for not having any recorded information on the items to be studied and, 70 constituted the study sample. In these there were no entries on: the immediate cause of CRA (92%); the interventions seeking to recover the cardiorespiratoy arrest (RCA) (71%); on the initial rate of CRA (59%); on the time of events (16%); on drugs used (50%); and, on the professionals involved in RCA (88%). CONCLUSIONS: The notes were scarce and often not realized. The use of the Utstein model favors the annotation sequence of events, avoiding data loss.
Keywords : Cardiopulmonary arrest; Nursing records; Death; Protocols.