Abstract

SILVA, Josy Anne; GROSSI, Ana Cândida Martins; HADDAD, Maria do Carmo Lourenço  and  MARCON, Sonia Silva. Quality assessment of nursing records in a semi-intensive care unit. Esc. Anna Nery [online]. 2012, vol.16, n.3, pp. 577-582. ISSN 1414-8145.  http://dx.doi.org/10.1590/S1414-81452012000300021.

Nursing records can be used as a method to assess quality of care. The aim of this study was to assess quality of nursing records in a semi-intensive care unit. Data were collected using a guide for retrospective audit, gathering information from 16 patients awaiting admittance into an Intensive Care Unit, admitted in the period of December 2009 to January 2010, with an average of 8 days of hospitalization. Regarding identification, the percentage of filled in records was 74.8%, which is close to acceptable standards (80%). However, the percentage of complete filled in items were respectively: nursing records, procedures and nursing prescription, intensive care and execution of medical orders accounting for 54.7%, 41.1%, 39.3%, 34.9% and 25%. The reduced levels of complete filled in records reveal a major flaw in recording care provided in this unit which may be hindering the continuance of care and is prejudicial to the legitimization of care provided by nurses.

Keywords : Nursing records; Nursing Audit; Quality of Health Care; Intensive Care.