Abstract

FRANCO, Maria Teresa Gomes; AKEMI, Elizabeth Nishio  and  D´INOCENTO, Maria. Evaluation of the nursing records in the medical records of patients hospitalized in an internal medicine unit . Acta paul. enferm. [online]. 2012, vol.25, n.2, pp. 163-170. ISSN 0103-2100.  http://dx.doi.org/10.1590/S0103-21002012000200002.

OBJECTIVE: To analyze the nursing records (RE) completed by nurses in patients' records of an internal medicine (CM) unit of a public hospital. METHODS: The study sample consisted of 240 (100%) records of patients who were discharged or died, between February and April, 2008. The classification criteria for completion were based on those established by the institution being researched. RESULTS: The records were filled out completely for the majority of the items: nursing history (99.9%); multidisciplinary progress (80.0%) and risk assessment (99.6%). Regarding the consistency of the completion, the highlights were: 88.4% of nursing prescriptions classified as compliant; diagnosis and nursing progress 58.7% and 64.6% as non-conforming, respectively. As to the identification of nursing: 98.3% completed the nursing history, 87.9% were in progress, and 75.4% of the diagnosis and nursing prescription. CONCLUSION: The detected nonconformities confront the importance given by the institution for completion of the records, training and vigilance of the audit committee of nursing.

Keywords : Evaluation; Medical records; Nursing records; Nursing process; Inpatients.