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Acta Paulista de Enfermagem

Print version ISSN 0103-2100

Abstract

BORSATO, Fabiane Gorni et al. Assessment of quality of nursing documentation in a University Hospital. Acta paul. enferm. [online]. 2011, vol.24, n.4, pp. 527-533. ISSN 0103-2100.  http://dx.doi.org/10.1590/S0103-21002011000400013.

OBJECTIVES: To assess the quality of nursing documentation in a university hospital. METHODS: We conducted a descriptive, quantitative research study with data collection supported by the available reports of quality assurance in nursing at the institution, from 2002 to 2009. Attributed to the item, "Documentation of Nursing", were these criteria: complete, incomplete, not filled in, and incorrect, for which was adopted as satisfactory: over 80%, below 15%, below 5%, and 0%, respectively. RESULTS: The division of inpatient satisfaction reached in 2007, with 82.2% of the documentation completed. The intensive care units did not achieve satisfaction in any of the criteria. The Maternal-Child Health Division had 90.7% of records complete in 2009. CONCLUSION: We detected advances in the quality of the records until 2009, pointing to the awareness of nursing professionals and to the investment in the institution's educational processes.

Keywords : Nursing records; Quality management; Nursing care.

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