OBJECTIVE: To evaluate the quality of nursing documentation on medical records of patients from a university hospital in São Paulo, Brazil. METHODS: A retrospective descriptive study was used to conduct the study. Four hundred and twenty four medical records of patients from medical and surgical units were reviewed from November 2006 to January 2007. The medical records were from patients who have been discharged from the hospital (56.1%) or those who have expired (43.9%). The focus of the review was on the demographic and background information, operation room flow sheet, nursing progress notes, nursing diagnoses, nursing orders, implementation of the nursing orders, medical orders, nursing documentation, discharge documentation, and documentation of death. RESULTS: The majority of nursing documentation was acceptable (64.7%). Only 8.7% of nursing documentation was of good quality. The remainder of nursing documentation was poor (26.7%). It is important to note that was difficult to measure nursing care outcomes reflected in nursing documentation on the medical records. This may affect patient safety and quality care. CONCLUSION: The findings of this study suggested deviation from recommended standards of nursing practice. They served to propose new goals and strategies to improve nursing documentation and the delivery of nursing care.
Quality of health care; Quality assurance health care; Nursing audit; Information management