Development of a medical record for residents in a long-stay institution for the elderly

Abstracts

OBJETIVO: Elaborar o prontuário do residente em uma instituição de longa permanência para idosos (ILPI) no Estado do Rio Grande do Sul. MÉTODOS: Trata-se de pesquisa-ação, realizada em uma ILPI, no Rio Grande do Sul/Brasil. Participaram dois pesquisadores e 14 trabalhadores: um enfermeiro, um médico, uma nutricionista, uma assistente social, quatro técnicas de enfermagem, duas cuidadoras e quatro administradores. Foram utilizadas as reuniões grupais com os participantes da pesquisa, durante as quais foram refletidos/discutidos quatro temas: finalidade do prontuário; composição do prontuário; contribuições do prontuário à ILPI; sugestões a respeito do prontuário. RESULTADOS: O prontuário do residente foi elaborado conjuntamente entre pesquisadores e trabalhadores da ILPI, atendendo às necessidades contextuais, sendo, posteriormente, implantado. Ficou composto pelos: dados pessoais do idoso; anamnese médica; evolução da equipe multiprofissional; prescrição médica e anotação da técnica de enfermagem; sistematização da assistência de enfermagem; avaliações cognitiva, afetiva, funcional e social. CONCLUSÃO: O prontuário elaborado trouxe melhor sistematização do cuidado para os trabalhadores e contribuição para melhoria da assistência aos idosos.

Idoso; Instituição de longa permanência para idosos; Registros médicos


OBJETIVO: Elaborar la ficha médica del residente en una Institución de Larga Permanencia para Ancianos (ILPA) en el Estado de Rio Grande do Sul. MÉTODOS: Se trata de investigación-acción, realizada en una ILPA, no estado de Rio Grande do Sul, en Brasil. Participaron dos investigadores y 14 trabajadores (un enfermero, un médico, una nutricionista, una asistente social, cuatro técnicas de enfermería, dos cuidadoras y cuatro administradores). Fueron utilizadas las reuniones grupales con los participantes de la investigación, durante las cuales se hicieron reflexiones y discusiones sobre cuatro temas: 1) finalidad de la ficha; 2) composición de la ficha; 3) contribuciones de la ficha a la ILPA; y, 4) sugerencias sobre la ficha. RESULTADOS: La ficha del residente fue elaborada conjuntamente entre investigadores y trabajadores de la ILPA, atendiendo a las necesidades contextuales, siendo, posteriormente, implantada. Quedó compuesta por: datos personales del anciano; anamnesis médica; evolución del equipo multiprofesional; prescripción médica y anotación de la técnica de enfermería; sistematización de la asistencia de enfermería; y, evaluaciones (cognitiva, afectiva, funcional y social). CONCLUSIÓN: La ficha elaborada mostró una mejor sistematización del cuidado para los trabajadores y contribuyó para la mejoría de la asistencia a los ancianos.

Anciano; Hogares para ancianos; Historia clinica


OBJECTIVE: To develop a medical record for residents in a long-stay institution for the elderly (LSIE) in the state of Rio Grande do Sul, in Brazil. METHODS: This was a research-action, conducted in a LSIE in the state of Rio Grande do Sul, in Brazil. Two researchers and 14 workers participated in the research (a nurse, a doctor, a nutritionist, a social worker, four nursing techniques, two caregivers and four administrators). It was utilized the group meetings with the participants, during the meetings were analyzed and discussed four themes: 1) purpose of the medical record; 2) composition of medical records; contributions of medical records to the LSIE; and 4) suggestions regarding medical records. RESULTS: To attend the contextual needs, the medical record of residents was developed jointly between researchers and the LSIE workers; the proposed medical record was implemented subsequently; it was composed of: personal data of the elderly; medical history; evolution of the multidisciplinary team; prescription and annotation of the nursing technique of care; systematization of nursing assistance; and, assessments (cognitive, affective, functional and social). CONCLUSIONS: The implemented medical record improved the systematization of care and contributed to improving the care for the elderly.

Aged; Homes for the aged; Medical records


ORIGINAL ARTICLE

Development of a medical record for residents in a long-stay institution for the elderly*

Elaboración de la ficha del residente en una institución de larga permanencia para ancianos

Silvana Sidney Costa SantosI; Rafaela Vivian ValcarenghiII; Edison Luiz Devos BarlemIII; Bárbara Tarouco da SilvaIII; Karina Silveira de Almeida HammerschmidtIV; Marília Egues da SilvaII

IPhD in Nursing. Professor of the Nursing College, Universidade Federal do Rio Grande - FURG - Rio Grande do Sul (RS), Brazil

IIGraduate Student (Masters') in Nursing at the Nursing College, Universidade Federal do Rio Grande - FURG - Rio Grande do Sul (RS), Brazil

IIIGraduate Student (PhD) of the Nursing College, Universidade Federal do Rio Grande. FURG. Rio Grande do Sul (RS), Brazil. CAPES scholar

IVGraduate Student (PhD) in Nursing at the Nursing College, Universidade Federal do Rio Grande - FURG - Rio Grande do Sul (RS), Brazil. Professor of the Nursing Department of Universidade Federal do Pampa - UNIPAMPA - Uruguaiana (RS), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To develop a medical record for residents in a long-stay institution for the elderly (LSIE) in the state of Rio Grande do Sul, in Brazil.

METHODS: This was a research-action, conducted in a LSIE in the state of Rio Grande do Sul, in Brazil. Two researchers and 14 workers participated in the research (a nurse, a doctor, a nutritionist, a social worker, four nursing techniques, two caregivers and four administrators). It was utilized the group meetings with the participants, during the meetings were analyzed and discussed four themes: 1) purpose of the medical record; 2) composition of medical records; contributions of medical records to the LSIE; and 4) suggestions regarding medical records.

RESULTS: To attend the contextual needs, the medical record of residents was developed jointly between researchers and the LSIE workers; the proposed medical record was implemented subsequently; it was composed of: personal data of the elderly; medical history; evolution of the multidisciplinary team; prescription and annotation of the nursing technique of care; systematization of nursing assistance; and, assessments (cognitive, affective, functional and social).

CONCLUSIONS: The implemented medical record improved the systematization of care and contributed to improving the care for the elderly.

Keywords: Aged; Homes for the aged; Medical records

RESUMEN

OBJETIVO: Elaborar la ficha médica del residente en una Institución de Larga Permanencia para Ancianos (ILPA) en el Estado de Rio Grande do Sul.

MÉTODOS: Se trata de investigación-acción, realizada en una ILPA, no estado de Rio Grande do Sul, en Brasil. Participaron dos investigadores y 14 trabajadores (un enfermero, un médico, una nutricionista, una asistente social, cuatro técnicas de enfermería, dos cuidadoras y cuatro administradores). Fueron utilizadas las reuniones grupales con los participantes de la investigación, durante las cuales se hicieron reflexiones y discusiones sobre cuatro temas: 1) finalidad de la ficha; 2) composición de la ficha; 3) contribuciones de la ficha a la ILPA; y, 4) sugerencias sobre la ficha.

RESULTADOS: La ficha del residente fue elaborada conjuntamente entre investigadores y trabajadores de la ILPA, atendiendo a las necesidades contextuales, siendo, posteriormente, implantada. Quedó compuesta por: datos personales del anciano; anamnesis médica; evolución del equipo multiprofesional; prescripción médica y anotación de la técnica de enfermería; sistematización de la asistencia de enfermería; y, evaluaciones (cognitiva, afectiva, funcional y social).

CONCLUSIÓN: La ficha elaborada mostró una mejor sistematización del cuidado para los trabajadores y contribuyó para la mejoría de la asistencia a los ancianos.

Descriptores: Anciano; Hogares para ancianos; Historia clinica

INTRODUCTION

The demographic and epidemiologic transformation caused by an increase of the Brazilian elderly population generated questions about the aging process and its impacts on the biopsychosocial aspects. Therefore, public policies with regard to the elderly population were created in the past few decades and an increasing concern towards elderly care, family and living could also be noticed. Considering that fact, Homes for the Aged have an important role assisting elderly people and their families, who do not have conditions to support them in their domiciles.

As to aging, the Brazilian legislation for social protection has progressed in recent years, and a landmark of such process was the Elderly Statute promulgation, through Law n.º 10.741, from October 1st 2003. According to it, elderly people have the right to dignified living conditions with their families, or at private or public Homes for the Aged. Such institutions have the obligation of maintaining housing conditions that meet the needs of elderly people as well as comply with sanitation norms. Thus, Homes for the Aged should offer appropriate physical facilities, be regulated, propitiate the preservation of family bonds and the participation of elderly people in the community, inside or out of the facilities(1).

With regard to health, the approval of Ordinance n.º 399, from February 22nd 2006 was a landmark for the Sistema Único de Saúde _ SUS (Brazilian Health System), for it publicizes the Pact for Life, working along with the SUS and its management, helping its consolidation(2). Six priority areas of action were established through this Ordinance, among them, elderly people's health.

The Pact emergence was an important advance, but there are still lots to be done in order for the SUS to effectively meet the health demands and needs of the Brazilian elderly population. Considering that, Ordinance n.º 2.2528, from October 19th 2006 was elaborated and approved, reorganizing the National Policy for Elderly People's Health, whose purpose is to "recover, maintain, and promote elderly people's [...] autonomy and independence, generating collective and individual measures towards health [...] in compliance with the SUS principles and guidelines"(3).

Among the questions related to elderly people's health, the population aging might trigger an increase in Chronic Non-Communicable Diseases that require several care modalities, which include care at Homes for the Aged. Such institutions become, day after day, more necessary due to the Brazilian elderly population increase and the difficulties faced by families when providing home care. Family caregivers agree that one of the difficulties is the activities overload they have to deal with, mainly when the caregivers are also elderly(4), for, in spite of the legal instruments, families do not receive enough support from health services to care for their dependent elderly relatives at home.

Homes for the Aged are facilities that provide integral care to people with 60 years of age or more who do not have conditions to live by themselves or stay with their families. Such institutions used to be called asylums, shelters, homes for the retired, homes for the elderly. They should count on a multi-professional team that meets their residents' needs(5).

Although there are structural, organizational and economic difficulties that include a shortage of workers and material resources at the Homes for the Aged, nurses, as part of the multi-disciplinary team, have to make a cooperative effort in order to optimize care provided to elderly people. Such action can be performed with help from the Multi-dimensional Assessment for the Elderly, where experience and resources are combined so as to focus on certain aspects of the aging process. The residents' records elaboration will be able to offer the assessment results, which consists of an essential step towards providing adequate care to institutionalized elderly people.

Records are basic documents that permeate administrative, legal, care-related, and research/teaching-related activities. They aim to register care provided by the multi-disciplinary team individuals. They are unique documents, where all the information regarding each client's health is, helping professionals communicate, which results in a better care/assistance(6).

The present research is justified by the need for records to be implemented at the Home for the Aged investigated, where the GEP-GERON study and research group has performed continuous and permanent activities _ such as elderly nursing care, contributions to the nursing administration, among others _ since 2004. This need emerged through a request made by the Conselho Regional de Enfermagem _ COREN/RS (Regional Nursing Council) after a visit to the Home for the Aged in question, to the GEP-GERON group, comprised of professors and students of the nursing college undergraduate and graduate programs, to contribute for a better care to be provided to the institution elderly people. It was difficult to find material describing the use and/or implementation of records at Homes for the Aged in the Brazilian literature. After a thorough literature search, a record model for residents at Homes for the Aged, elaborated by the Sociedade Brasileira de Geriatria e Gerontologia/São Paulo - SBGG/SP (Brazilian Society of Geriatrics and Gerontology/São Paulo), was found. Comprised of a group of forms, scales and tests to follow up on the institutionalized elderly in a multi-disciplinary way, it has 18 pages with: The elderly personal data; Medical anamnesis; Medical diagnosis hypothesis; Evolution; Complementary exams; Contact between the multi-professional team and the families; Nursing Care Systematization (NCS); Mini-Mental State Exam (MMSE); Verbal fluency test and Clock Drawing Test; Geriatric Depression Scale (GDS) with 30 questions; KATZ Scale; Life history(5). After the material found was organized, a meeting with the administrators of the Home for the Aged took place and a commitment to elaborate a record model was made, as long as the whole institution team helped the group in this challenge. Considering that, the research and study objective was presented to the administrators of the Home for the aged. After reaching an agreement, the first meeting with the "work group" was held.

Coming from such needs/agreements, the research question was: how can the residents' records elaboration at a Home for the Aged contribute to the improvement of institutionalized elderly care by the workers? In an attempt to answer this question, the present research objective was to elaborate residents' records for the elderly staying at a Home for the Aged in Rio Grande do Sul, Brazil.

METHODS

The present is a research-action study and an investigation related to the several ways a collective action can take place, and the problems or objectives that motivate transformation(7).

The research-action is a way of amplifying not only the higher education institutions limits, but also the relationship between academic researchers and the open public, contributing to a positive re-structuring of the university-society relationship(8), and producing satisfactory changes.

The research-action has 11 characteristics, namely: innovative, continuous, strategically pro-active, participative, interventionist, problematized, deliberate, documented, understood, context-specific, and disseminated. This type of research needs a theoretical/referential base to help understand situations, plan effective improvements and explain results. By utilizing it, the researcher works as a change facilitator, consulting the participants with regard to the action and assessment processes(7).

The research-action took place at a Home for the Aged in the state of Rio Grande do Sul, Brazil _ a philanthropic institution with more than 100 years old, where 60 elderly people live.

The investigation occurred between August 2006 and July 2007. Its stages were: theme definition, residents' record model presentation at the Home for the Aged in question; seminar performances through meetings; participants' qualitative representation: both for researchers and workers at the Home for the Aged; data collection through collective interviews; learning sessions including formal/informal knowledge; action plan elaboration through the residents' records adaptation/construction; and publicizing, which has been performed through Nursing and Gerontoloy scientific events.

Two researchers and 14 workers from the Home for the Aged took part in the study. The inclusion criteria for workers was: to have been providing direct or indirect care to the resident elderly people for at least three months; to be part of the administration of the Home; to sign the Informed Consent Term; to allow data to be published; to be willing to participate in the work group. In order to keep anonymity, participants were named "P" and numbered from 1 to 16 in the testimonies (P1-P16).

The 2 researchers-participants in the study were: a professor with a PhD in nursing, and specialist in gerontology, and an undergraduate student in nursing attending the last semester, part of the GEP-GERON study and research group, performing an extension project for more than a year. The other participants were: one nurse, one doctor, one nutritionist, one social assistant, four nursing technicians, two caregivers, four administrative staff workers. Only two professionals did not participate in the research: one of which did not meet the inclusion criteria concerning time of work at the Home for the Aged and the other one refused to participate.

The data collection and analysis occurred concomitantly and collectively. These stages were performed through five meetings (seminars), with a one month interval between them, and each one lasting for about one hour, except the last one, which took almost two hours. In these meetings, collective reflections/discussions on specific themes meeting the research objectives took place. Group reflection is an essential step in the research-action process(8). In the first meeting, the SBGG/SP record model was presented and its purpose and application at the Home for the Aged in question discussed; in the second meeting, creating a record model that met the Home needs was the focus; in the third meeting, the record model contribution to the Home for the Aged was discussed; in the fourth meeting, suggestions on that specific institution records were requested; in the fifth and last meeting, the results of the record model elaborated by the group and applied to one resident elderly person were presented, and aspects of it were modified through pertinent questions. Fifteen days after the work group fifth meeting, the investigated Home for the Aged resident record model was concluded.

The data collection and analysis stages were considered concomitant and complementary for during data collection, the intervention/research-action took place, and during analysis, the partial and final scientific registers were performed in a thorough way.

As to the ethical aspects, the president of the Home for the Aged authorized the research development. The project was submitted to the Comitê de Ética e Pesquisa na Área da Saúde da Universidade do Rio Grande (Committee for Health Area Ethics and Research of Universidade do Rio Grande) and received a favorable legal opinion, number 084/2006. The precepts of Resolution n. 196/96 were utilized, for it is considered that ethical principles should support and legitimate the research-action procedures(8).

RESULTS

Results were presented through the work group meetings (seminars) participants' opinions and the resident's record model description elaborated through the research-action.

Record Model Purpose

The theme discussed during the work group first meeting (seminar) was the record model purpose. After presenting the Home for the Aged resident's record model, elaborated by SBGG/SP, the reflection/discussion was initiated. It was possible to verify the importance of records and their main purpose, which is to help the multi-professional team improve care, by providing knowledge of each elderly person's health state, cognitive and functional conditions, among other information. Records allow written scientific documents to permanently exist, as well as information concerning one's health and care provided. Participants considered records had the following purposes:

They are important. They provide a more general understanding of each elderly person, because each one of them has their own particularities, specific pathologies, their own personality, personal history, and it is important to know about these things, because not only pathologies determine treatments, but also, the elderly personal needs. (P1)

[...] it provides the elderly person's diagnosis, and through the records we can solve doubts we might have about it.(P4)

[...] it facilitates work, containing all the information about the elderly person. (P6)

[...]. To know who the 'patients' are, how they are, how they have been evolving, helping the team acquire a greater local reality knowledge. (P9)

Records Composition

Still using the Home for the Aged resident's record model, elaborated by SBGG/SP, the second meeting focus was the model composition, considering its context and specificities. The group concluded that records should have as much information as possible about the elderly person so as to help providing specific care to each individual according to their needs and particularities. Participants agreed records should contain:

The elderly person's pathological history, family contacts, feeding aspects. (P 3)

Data about the elderly person, anamnesis, physical exam, life story from childhood to adult life, family contacts, sanity, past intercurrences. (P 2)

Information about the elderly person, medication, life matters regarding the elderly person and his/her family. (P 11)

Data [...] about health, NCS, emotional aspects, life matters (if the elderly person is dependent or independent, lucid). (P 14)

In the second meeting, the idea was to create records to meet the researched Home for the Aged needs. One of the researchers, along with two other participants, was responsible for placing the necessary adaptations to the SBGG/SP record model and send them via e-mail for the other participants' appraisal. The material was scanned, typed, and adapted according to previous discussions and sent to the research-action participants. Some modifications were agreed upon: only the MMSE should remain part of the cognitive assessment, for it comprehends the complete elderly person's cognitive assessment; the chosen Geriatric Depression Scale was abbreviated, containing 15 questions, for it provides the same reliability and validity the longer scale _ with 30 items _ does. It is also easier for the professionals to apply; the social assessment was modified in order to better meet the resident elderly people's needs.

Records contributions to the Home for the Aged

In the third meeting, once the institution "own" record model had been composed, it was possible to notice the participants' satisfaction with the work performed, manifested via email. During this meeting/seminar, the reflection/discussion theme proposed was the possible contributions residents' records could bring to the investigated Home for the Aged. As previously described, records are a communication vehicle among team members(6), favoring elderly care and future assessments of the care provided, as well as necessary and pertinent interventions to the institutionalized elderly people. The contributions mentioned by the participants were:

For the professionals: a wider knowledge of each elderly person, a multi-professional knowledge, which is a faster way to interact with a co-worker or an elderly person, facilitating access to urgently needed information, such as past intercurrences, history. For the elderly people: a way for them to obtain better care, and describe their own health state, providing their personal impression about themselves. (P 5)

For workers: [...] to obtain knowledge about the elderly person's pathologies and intercurrences. And for the elderly people, it means receiving more appropriate care. (P 16)

For the professionals: it simplifies how knowledge about the elderly is acquired. And for the elderly: it facilitates care to be provided. (P 10)

Suggestions concerning the record model

In the fourth meeting, having the institution "own" record model, participants in the work group discussed it and made suggestions on how to implement it. Some of the participants' suggestions were:

Having more information about the elderly person's family. (P 12)

Information about what the elderly person likes to do, the recreational time. (P 7)

It is important to go deeper in the social aspect. (P 13)

Implementing a computer system for the records so that everybody could access them. (P 16)

Suggestions were accepted; the social assistant made some observations about important social information for elderly people being admitted at Homes for the Aged, thus, other questions were added to the social assessment. Records were then typed in Word. The last suggestion allowed data to be entered and rescued, so as to easily know about the elderly person and care provided. Informatization should be seen as an additional tool to facilitate and dynamize services.

In the fourth meeting, one of the researchers suggested using it with one of the Home for the Aged elderly residents to validate the resident's record model elaborated. Everybody agreed with the suggestion. Therefore, a small group was formed with: one researcher and two workers so as to perform the test. The items verified through the validation were: application time, feasibility of questions, and results presentation in the fifth work group meeting.

In the fifth and last meeting, the record model application results were presented, as well as pertinent modifications made to it. During such meeting, the investigated Home for the Aged resident's record model was elaborated. The process was then assessed and participants celebrated, demonstrating satisfaction after the collective work had been concluded.

Some positive aspects concerning the performed research-action were: researchers brought printed copies of the material to be discussed; computers could be accessed (a desktop and a laptop), as well as a printer, which facilitated work; meetings were organized by one of the researchers; work group commitment; participants were served coffee and water during meetings. Some negative aspects were: among the 16 participants, only 10 attended all meetings; one of the participants was only present in two meetings; participants' reflections/discussions/testimonies were a lot deeper, however, summarized versions of their contributions had to be used in the final research-action report.

Presentation of the resident's record model implemented at the selected Home for the Aged

The record elaborated has a total of 16 pages: - The elderly person's personal data: identification, complete name, register number, nationality, hometown, religion, birth date, marital status, number of children, filiation, educational level, profession, document type and number, health insurance, provenance (domicile, hospital, another institution or somewhere else). Data concerning the person responsible for the elderly and his/her admission, complete name, age, profession, relationship, General Register (RG _ Brazilian identification Document), Social Security number (CPF in Brazil), complete address and telephone number, complete commercial address and telephone number. There are also data about other people to contact, which includes their complete name, relationship, and telephone numbers. Who indicated the Home is another item (physician, client, relatives, a media article, telephone services, websites); besides the date the elderly person was admitted at the Home for the Aged, as well as time and a signature from the person responsible for it.

- Medical anamnesis: current disease history (CDH); medication; general information (anorexia, sight, hearing, breathing, cardiovascular information, digestive information, emaciation, dental prosthetics, constipation, incontinence, depression, cognition, sleep, agitation, fever, dysphasia, prostatism, dizziness); pathological and family histories; habits and addictions; physical exam (weight, height, CW, skin, wrists, carotid, ganglion, mucous membranes, thyroid, breathing, cardiovascular system, abdomen, genitourinary system, locomotion, neurological system), and diagnosis hypothesis.

- Multi-professional team evolution: date, evolution and signature.

- Medical prescription and notes from the nursing technician: date, medical prescription, time; notes from the nursing technician and signature.

- Nursing Process (NP): Nursing history (reasons for admission, vital signs, risk factors, such as tabagism and alcoholism, medication in use _ name, dosage, and time; body care, sleep and rest, feeding, urinary and intestinal excretion, sexual activity); nursing physical exam (reporting weight loss, awareness level, Deambulation, skin and tissue conditions, sight and hearing conditions, head and neck, pulmonary auscultation, breasts, cardiac auscultation, abdomen, genitourinary system, upper and lower limbs, other complaints); nursing diagnosis identified through North American Nursing Diagnosis Association (NANDA) Taxonomy II; nursing actions; date; nurse's signature.

- Cognitive assessment: uses the Mini-Mental State Exam (MMSE), whose test is widely utilized to assess elderly people's cognition, besides being a tracking instrument. The cognitive assessment also contains the resident's name and birth date(4,9,10).

- Affective assessment: defined by the Geriatric Depression Scale (GDS) comprised of 15 questions developed to assess whether the elderly person presents affective disorder indications or not(4,9,10).

- Functional assessment: performed through the KATZ scale, which assesses the elderly person's functional state. It measures the individual's ability to perform basic daily life tasks (BDLT) in an independent way. The independence determination might lead to the identification of abilities and limitations, thus guiding appropriate actions to be taken according to the elderly person(4,9,10).

- Social Assessment: performed through the elderly person's life history, considering his/her childhood and adult life reports; important facts in personal and professional life; person who suggested the elderly person lived at the Home for the Aged and reason why; name of the person responsible for taking the elderly for admission and their relationship; leisure activities (something the elderly person does not do, but would like to); information whether the elderly person tends to look for a doctor or nurse in case they have any health problems; among other questions.

Data recorded about elderly residents at a Home for the Aged are essential and need to be standardized so as to follow up on individual evolution. Resident records are instruments that can guarantee better care to be provided by the nursing and health team.

DISCUSSION

One of the present research intentions was to consider the dialogue with other authors with regard to the nurse's importance in teams working at Homes for the Aged; also, to use the research-action results, and the participants' testimonies during the meetings/seminars to collectively build the resident's record model.

As to the work group characterization, it is important to remember that the nurse has an essential role identifying the modifications the aging process brings, as well as perceiving manifested or non-manifested needs. They also need to determine actions that will improve quality of life, and provide individualized care, trying to maintain the elderly person's independence and autonomy(11).

With regard to the records purpose according to how participants see it, everybody agreed they should contain sufficient information to identify the elderly person, and thus, to fulfill their primary role, which is to be an effective communication channel among team members, resulting in better care provided to the institutionalized elderly person. Records aim to facilitate communication among professionals; and it is a vehicle for teaching and researching; it is possible to assess service through records, and they can be used as legal documents in case of an audit(6).

As to the records composition, nursing records are performed using the nursing process (NP), and supported by the Theory of Basic Human Needs, by Wanda Aguiar Horta. The NP considers as being history _ elaborated using a checklist _ nursing diagnosis, prescription and evolution. The currently used nursing diagnoses comply with NANDA International, its definitions and classifications, from 2009-2011(12).

Concerning the contributions records brought to the Home for the Aged, such managerial tool represents a group of standardized documents, which should be ordered and summarized, and contain all information about care provided to the clients by the health workers. Notes in the records or clinical files should be readable, and allowing health professionals involved in providing care to be identified(6).

One of the suggestions concerning the resident's records elaboration was to informatize them. The use of information technology systems presents wide benefits to care providers and clients in general. This type of technology provides a better integration of information sources and a better information access, facilitating care to be provided by caregivers, and contributing to accuracy regarding information related to the elderly person's general assessment(9).

It was possible to notice that the research-action was a feasible methodological approach in the nursing area, for it involves people in an attempt to solve problems; it helps interested groups of professionals to develop; it diminishes the distance between researchers and workers, because everyone is part of the research-action; and mainly, it presents an emancipative character(8).

CONCLUSION

The study objective was reached, for the resident's record model was implemented meeting the investigated Home for the Aged and research group's needs, through the research-action. The records informatization was initiated so that workers/researchers working at the Home for the Aged could easily access them.

The research-action methodology proved to be appropriate to the investigation process, in compliance with the established investigation objective. Meetings and collective reflections/discussions were interesting and helped the involved individuals better know each other and reach the expected results: the construction of a product, in this case, a record model elaboration and implementation at a specific Home for the Aged.

The record model implementation at the investigated Home for the Aged proved to be an important tool to the institution organization and established a better care systematization, contributing to the improvement of care provided to the resident elderly.

This research is expected to contribute to a better organization within Homes for the Aged, and improve workers' knowledge of the elderly people they are working with, their particularities, individual needs, providing better care through work systematization.

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  • 9. Tier CG. Depressão em idosos residentes em uma instituição de longa permanência (ILP): identificação e ações de Enfermagem e Saúde [dissertação]. Rio Grande: Programa de Pós Graduação em Enfermagem da Fundação Universidade Federal do Rio Grande; 2006.
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    North American Nursing Diagnosis Association. Diagnósticos de enfermagem da NANDA: definições e classificação 2009-2011. Porto Alegre: Artmed; 2010.
  • 11. Lueckenotte AG. Avaliação em gerontologia. 3a ed. Rio de Janeiro: Reichmann & Affonso Editores; 2002.
  • 12. Tavares DMS, Pereira GA, Iwamoto HH, Miranzzi SSC, Rodrigues LL, Machado ARM. Incapacidade funcional entre idosos residentes em um município do interior de Minas Gerais. Texto & Contexto Enferm. 2007;16(1):32-9.

  • Autor Correspondente:
    Silvana Sidney Costa Santos
    R. Duque de Caxias, 197/503 - Centro
    Rio Grande - RS - Brasil - CEP. 96200-020
    E-mail:
  • *
    Artigo extraidode pesquisa de iniciação científica financiada pelo CNPq. PROBIC-FURG.

Publication Dates

  • Publication in this collection
    13 Jan 2011
  • Date of issue
    2010

History

  • Received
    04 Nov 2009
  • Accepted
    06 Aug 2010
Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: ape@unifesp.br