Manual for monitoring the quality of nursing home care
               records

methodological study involving the elaboration of a manual, whose content was later submitted to six experts for validation, reaching a ≥ 80% consensus. The data collection process was carried out in 2012 by means of a questionnaire comprised of the following issues: nursing evolution, nursing diagnosis, and nursing prescription, and standards for the nursing team recommended by the Regional Nursing Council of São Paulo and by the assessed institution. Manual items were judged according to the following variables: relevance, pertinence, clarity and simplicity.

Results:

of the 39 propositions, 100% achieved ≥ 80% agreement in the relevance, pertinence and clarity variables; 92.3% in the simplicity variable. Sleep/rest, Mobility and Check-out variables did not reach a favorable minimum consensus in the prescribed activities and were improved following suggestions from the experts.

Conclusion:

we believe that the instrument will enable the improvement of the HCP’s work process.

Key words:
Home Nursing; Information Management; Nursing

Manual’s items	Relevance				Clarity				Pertinence				Simplicity
	Yes		No		Yes		No		Yes		No		Yes		No
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Patient identification	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Identification of nursing diagnosis	6	100	0	0	5	83,3	1	16,7	6	100	0	0	6	100	0	0
Date of nursing diagnosis	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Nursing evolution	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Record of probes, catheters and others	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Record of vital signals	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Signature after nursing diagnosis	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Stamp after nursing diagnosis	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Identification of nursing prescription	6	100	0	0	5	83,3	1	16,7	6	100	0	0	6	100	0	0
Record of prescribed activities (nursing or family)	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Check out prescribed activities	6	100	0	0	6	100	0	0	6	100	0	0	4	66,7	2	33,3
Date of nursing prescription	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
There is at least one nursing prescription for each nursing diagnosis	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Signature after nursing prescription	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Stamp after nursing prescription	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0

Manual’s items	Relevance				Clarity				Pertinence				Simplicity
	Yes		No		Yes		No		Yes		No		Yes		No
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Patient’s identification data	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
First assessment home visit	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Previous history	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Home conditions	6	100	0	0	6	100	0	0	6	100	0	0	5	83,3	1	16,7
Medical diagnosis at hospitalization	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Family structure (caregiver)	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Physical exam	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Emotional status	6	100	0	0	6	100	0	0	6	100	0	0	5	83,3	1	16,7
Communication sources	6	100	0	0	5	83,3	1	16,7	6	100	0	0	6	100	1	16,7
Food	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Elimination	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Sleep and rest	6	100	0	0	5	83,3	1	16,7	6	100	0	0	4	66,7	2	33,3
Mobility	6	100	0	0	5	83,3	1	16,7	6	100	0	0	4	66,7	2	33,3

Manual’s items	Relevance				Clarity				Pertinence				Simplicity
	Yes		No		Yes		No		Yes		No		Yes		No
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Clear information	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Objective information	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Readable handwriting	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Blank lines or spaces	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Information written with a pen	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Date of first home visit	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Time of first home visit	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Signature	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Stamp	6	100	0	0	6	100	0	0	6	100	0	0	6	100	0	0
Erasure	6	100	0	0	5	83,3	1	16,7	6	100	0	0	5	83,3	1	16,7
Adequate erasure correction	6	100	0	0	5	83,3	1	16,7	6	100	0	0	5	83,3	1	16,7

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] CORRESPONDING AUTHOR: Silvia Freitas Barbosa E-mail: silvia.barbosa@usp.br