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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234On-line version ISSN 1980-220X

Rev. esc. enferm. USP vol.53  São Paulo  2019  Epub Aug 19, 2019

https://doi.org/10.1590/s1980-220x2018003703471 

ORIGINAL ARTICLE

Documentation of the nursing process in public health institutions

Oswalcir Almeida de Azevedo 1  
http://orcid.org/0000-0001-7466-6284

Érika de Souza Guedes 1  
http://orcid.org/0000-0001-5220-4142

Sandra Alves Neves Araújo 2  
http://orcid.org/0000-0002-7341-0911

Magda Maria Maia 3  
http://orcid.org/0000-0002-3089-0986

Diná de Almeida Lopes Monteiro da Cruz 4  
http://orcid.org/0000-0003-1373-409X

1Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem na Saúde do Adulto, São Paulo, SP, Brazil.

2Universidade Nove de Julho, São Paulo, SP, Brazil.

3Secretaria de Estado da Saúde de São Paulo, Programa de Triagem Neonatal e Doenças Raras, São Paulo, SP, Brazil.

4Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil.


ABSTRACT

Objective

To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health.

Method

A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations.

Results

Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors.

Conclusion

Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.

Key words: Nursing Records; Nursing Process; Nursing Services; Practice Patterns, Nurses’

RESUMO

Objetivo

Identificar a prevalência de documentação do Processo de Enfermagem nos hospitais e ambulatórios administrados pela Secretaria de Estado da Saúde de São Paulo.

Método

Estudo descritivo, realizado por meio de entrevistas com enfermeiros responsáveis por 416 setores de 40 instituições sobre a documentação de quatro fases do Processo de Enfermagem (levantamento de dados, diagnóstico, prescrição e evolução) e de anotações de enfermagem.

Resultados

Dos 416 setores estudados, 89,9% documentavam pelo menos uma fase; 56,0% documentavam as quatro fases; 4,3% documentavam apenas anotações de enfermagem; 5,8% não documentavam nenhuma fase, nem as anotações de enfermagem. Os tipos de setores que menos documentavam foram: ambulatório, apoio diagnóstico, centro cirúrgico e centro obstétrico; os que mais documentavam: unidades de terapia intensiva, prontos-socorros e unidades de internação. O levantamento de dados e o diagnóstico foram as fases menos documentadas, ambas em 78,8% dos setores.

Conclusão

A maior parte dos setores estudados documenta o Processo de Enfermagem e faz anotações de enfermagem, mas há setores em que a documentação não corresponde às exigências formais. A viabilidade da documentação de todas as fases do Processo de Enfermagem em determinados tipos de setores precisa ser mais bem estudada.

Palavras-Chave: Registros de Enfermagem; Processo de Enfermagem; Serviços de Enfermagem; Padrões de Prática em Enfermagem

RESUMEN

Objetivo

Identificar la prevalencia de documentación del Proceso de Enfermería en los hospitales y ambulatorios administrados por la Secretaría de Estado de la Salud de São Paulo.

Método

Estudio descriptivo, llevado a cabo mediante entrevistas con enfermeros responsables de 416 sectores de 40 centros acerca de la documentación de cuatro fases del Proceso de Enfermería (inventario de datos, diagnóstico, prescripción y evolución) y de apuntes de enfermería.

Resultados

De los 416 sectores estudiados, el 89,9% documentaban por lo menos una fase; el 56,0% documentaban las cuatro fases; el 4,3% documentaban solo apuntes de enfermería; el 5,8% no documentaban ninguna fase, ni los apuntes de enfermería. Los tipos de sectores que menos documentaban fueron: ambulatorio, apoyo diagnóstico, quirófano y centro obstétrico; los que más documentaban: unidades de cuidados intensivos, urgencias y unidades de estancia hospitalaria. El inventario de datos y el diagnóstico fueron las bases menos documentadas, ambas en el 78,8% de los sectores.

Conclusión

La mayor parte de los sectores estudiados documenta el Proceso de Enfermería y hace apuntes de enfermería, pero hay sectores en los que la documentación no corresponde a los requerimientos formales. La factibilidad de la documentación de todas las fases del Proceso de Enfermería en determinados tipos de sectores necesita ser más bien estudiada.

Palabras-clave: Registros de Enfermería; Proceso de Enfermería; Servicios de Enfermería; Pautas de la Práctica en Enfermería

INTRODUCTION

The proper management of healthcare to ensure safety, effectiveness, quality, sustainability and positive experiences to users and professionals fundamentally depends on communication among health professionals. Clinical documentation is an instrument for communication between these professionals1 - 3 . The quality of clinical documentation has therefore been the object of policies, norms and guidelines of health services and of organizations which guide or regulate health actions.

The Federal Nursing Council ( COFEN – Conselho Federal de Enfermagem ) in Brazil made it compulsory to document all phases of the Nursing Process (NP)4 in 2002, and health services have been preparing to meet this requirement since that time.

In order to comply with this requirement, the São Paulo State Department of Health ( SES/SP – Secretaria de Estado da Saúde de São Paulo ) started the Tecendo SNC (Systematization of Nursing Care) project in 2003 with the purpose of encouraging and supporting NP implementation in hospitals and clinics of the state network. This initiative sought to improve the quality of healthcare, strengthen management for quality, including awareness-raising and training of nursing professionals in hospitals and outpatient clinics linked to the SES/SP5 . A situational diagnosis of institutions linked to SES/SP6 in 2004 showed that the NP was implemented in more than half of the state hospitals (66.7%) and ambulatory hospitals (53.8%) of the state network in 70% to 100% of the service sectors. However, the use of isolated NP stages predominated, with priority on the prescription and evaluation of nursing.

Considering the importance of clinical nursing documentation, the documentation requirement of all phases of the NP in Brazil and the efforts of SES/SP to implement the NP, a research project7 was started in partnership with the SES/SP and the Nursing School of USP ( Universidade de São Paulo ) in 2009 to describe the documentation situation of the NP in the institutions under direct administration of SES/SP. Part of the results of this project are reported in this article.

NP IMPLEMENTATION AND DOCUMENTATION

Nursing process is the term used to identify an organization form of nurses’ work. It consists of a way of organizing care in order to inscribe quality into the care provided.

The terminology was disseminated in Brazil by Horta8 in the 1970s. It currently refers to the development of nursing care in the following stages: data collection or nursing assessment – physical and historical examination; nursing diagnosis - nurses’ decisions about the patient’s responses which require nursing care; planning-determination of patient-sensitive nursing outcomes and interventions to achieve them; implementation of nursing interventions - proposed treatment; and nursing evaluation – analysis of the patient’s progress in relation to the expected results9 . This last stage is also called nursing evaluation5 - 7 . All these steps require accurate documentation, since they represent activities developed in providing care to the patient, implying professional and legal aspects for the nurse, the multiprofessional team and the patient. Documentation represents the only viable and safe way of systematically knowing what has been done.

Accurate registration, which can be facilitated through using computer programs10 - 11 , is pointed out in the literature as a way to improve communication among professionals1 - 3 , to ensure the care continuity plans12 , as well as the integrity and regularity of patient information13 . These aspects should be highlighted when initiating a program to encourage adoption of the NP and the documentation resulting from it. However, it is not prudent to ignore the difficulties involved in the process of implementing NP documentation, which must be acknowledged when developing the strategic planning of the change process. Some difficulties pointed out by the authors involve operational issues such as staff shortage and staff preparation, work overload, work division model and high turnover of nurses. Other more complex difficulties refer to the need for reflexive action and theoretical foundations by the team to establish clear institutional policies for the nursing staff, to intentionally and deliberately adopt a nursing care model which is compatible with using the NP, to value this work model by the nurses, in addition to the resistance to change associated with the set of beliefs and values, to the use of standardized language and to dissatisfaction with the working conditions10 , 12 , 14 .

Although recognized by the category as a way of giving credibility and transparency to nursing activities in general, implementing NP documentation requires reorganization and systematization of health practices7 , 12 , 15 , which constitutes a challenge. Among barriers identified for its implementation are the organizational structure12 , a lack of time for professionals3 , shortage of human and material resources, refusal of professionals and the need for continuous training14 . On the other hand, the literature shows several benefits: improving the care quality and professional satisfaction1 , 15 , providing greater visibility to nurses, valuing their actions, promoting autonomy and efficiency to them, and offering scientific bases to the profession16 .

For more than 15 years, NP implementation in health care units in Brazil has been encouraged, and the COFEN, initially with the COFEN Resolution 272/20024 , established general norms regarding use of NP in health institutions where there were nurses, determining that this work method be implemented throughout the national territory. Prior to this Resolution, Law 7.498/8617 , the Nursing Professional Exercise Law, provided for nursing prescription (Art. 3) and nursing consultation (Art. 11). However, only 16 years later, COFEN regulates NP implementation in clinical practice, establishing that the actions related to it are the nurse’s prerogatives, describing the steps and highlighting the need for their documentation. The autarchic documents currently in force are COFEN Resolution 358/200918 , which repeals, expands and updates the concepts of the previous resolution4 according to knowledge development in nursing and the understanding of the NP, and COFEN Resolution 429/201219 , which establishes the need for nursing documentation in the patient’s health records in the following terms: “Art. 1 – It is the responsibility and duty of Nursing professionals to record the information inherent to the process of caring for and managing the work processes which are necessary to ensure care continuity and quality in the patient’s health records and other documents of the area, whether in the medium of traditional (paper) or electronic support”.

The records recommended by the COFEN standards include personal and family data of the patient, nursing diagnosis, nursing interventions performed related to the diagnoses, results from the interventions and other information relevant to “dignified, sensitive, competent and decisive care”19 .

Considering the formal requirement of NP documentation and the specific institutional contexts in terms of facilities and barriers to implementing the NP, the SCE/SP Tecendo SNC Project5 - 6 sought to coordinate organizational management actions which locally facilitated successful implementation of NP in hospitals and clinics10 , 20 . Describing the NP documentation situation in SES/SP institutions enables identifying weaknesses and potentialities in the adherence to the COFEN regulations regarding the documentation of nursing in the state of São Paulo, providing systematically obtained empirical data to develop knowledge about the clinical documentation of nursing.

Therefore, the objective of this study was to identify the prevalence of NP documentation in hospitals and outpatient clinics administered by the SES/SP.

METHOD

STUDY DESIGN

This is a quantitative, descriptive and cross-sectional study.

SCENARIO

Health institutions (hospitals, clinics and clinics) managed by SES/SP were included in the study. The results presented herein are part of a larger study whose methods are detailed in another publication7 . For the study, the 43 health institutions administratively linked to SES/SP were invited, of which 40 (93%) participated. Prolonged negotiations to obtain authorization from the directorates for the data collection as well as to perform the study was what motivated non-participation of three of the 43 eligible institutions.

DATA COLLECTION

Data on NP documentation were obtained through face-to-face interviews with the nurse responsible for the sector. The action area of nursing professionals was defined as collected from a monthly nursing work shift schedule. It was necessary for the sector to involve the presence of patients/users to be included in the study; there were no exclusion criteria. The interviews were conducted in the years 2011 to 2012 by trained research assistants and were guided and recorded in a specific form for the project. They answered questions about the NP operationalization of 416 nurses.

The studied variables included:

The presence of NP documentation – any institutional initiative of nursing documentation in the patient’s health records according to the stages of the NP, regardless of the number of phases documented systematically. The presence of the NP was regularly accepted from patients’ records or from verbal reports of nurses working in a hospital or outpatient unit, in at least one of the following phases: data collection, nursing diagnosis, prescription of nursing and evaluation of nursing.

NP phases used – verbal nurses’ report confirming documenting data collection, diagnoses, prescription and evaluation. The documentation of nursing notes was also investigated, understood in the study as the record traditionally made by nurses on the patient’s chart without specifying any of the NP phases.

The institution sector types constituted the nurses’ description of the care offered locally: general hospitalization, intensive care unit, emergency room, and operating room, among others. The SES/SP information system brings together beds and outpatients according to the type of care (medical clinic, surgical clinic, pediatrics, gynecology and obstetrics, for example), and other productivity data are consolidated according to this categorization. There were no categories in the SES/SP electronic information systems corresponding to the sectors/units according to the nursing staff organization in the institutions.

DATA ANALYSIS AND PROCESSING

The data were input into Sphinx®software and later migrated to MS Excel®software for descriptive analyzes.

ETHICAL ASPECTS

The study was approved by the Research Ethics Committee of the Nursing School of the Universidade de São Paulo, under Process no. 856/2009. It met the guidelines of Resolution 196/96, updated by Resolution no. 466/12 of the National Health Council. All participants signed the Informed Consent Form.

RESULTS

All the service sectors (429) that had a nursing staff scale were eligible for the study, ranging from one to 28 sectors among the different institutions, but not all participated ( Table 1 ).

Table 1 – Number of sectors participating in the study according to the sector types – São Paulo, SP, Brazil, 2011-2012. 

Sector types Participation in the study Total

No Yes
General admission (GA) 1 (0.5%) 201 (99.5%) 202
Ambulatory (AB) 6 (9.5%) 57 (90.5%) 63
Intensive Care Unit (ICU) 2 (3.7%) 52 (96.3%) 54
Emergency Room (ER) 1 (2.7%) 35 (97.2%) 36
Surgical Center (SC) - 22 (100%) 22
Diagnostic Support Service (DSS) 3 (14.3%) 18 (85.7%) 21
Obstetric Center* (OC) - 16 (100%) 16
Day Hospital (DH) - 9 (100%) 9
Center for Psychosocial Care (CPC) - 6 (100%) 6

General Total 13 (3.0%) 416 (97.0%) 429

* Includes a Normal Delivery Center unit. Note: (N=429).

Of the 429 sectors considered, data collection was not performed in 13 ( Table 1 ) due to the nurses’ lack of availability to respond to the questionnaire or their refusal to participate. Therefore, the total number of sectors in the next results is 416.

In order to facilitate the results’ presentation, we refer to nursing annotations as one of the NP documentation categories ( Table 2 ), although strictly speaking such designation does not apply. From this point forward all data correspond to the total number of participating sectors (N=416).

Table 2 – Positive reports of documentation according to the NP documentation category and the sector types – São Paulo, SP, Brazil, 2011-2012. 

Documented NP phases Sector types* Total n (%)**

GA AB ICU ER SC DSS OC DH CPC
Data collection 166 34 48 30 14 5 13 7 5 328 (78.8)
Diagnosis 186 26 51 30 11 2 13 6 5 328 (78.8)
Prescription 187 27 52 59 14 6 13 8 6 343 (82.5)
Evaluation 196 35 52 31 17 5 13 8 5 362 (87.0)
Notes 195 39 52 5 19 11 15 9 5 378 (90.9)
None 1 13 - 1 1 7 1 - - 24 (5.8)

Total of responses 931 174 255 126 76 36 67 38 26 1758

Total of units 201 57 52 35 22 18 16 9 6 416

Mean (phases/sector) 4.6 3.0 4.9 3.6 3.5 2.0 4.2 4.2 4.3 4.2

* GA = General Admission for hospitalization; AB = Ambulatory; ICU = Intensive Care Unit; ER = Emergency Room; SC = Surgical center; DSS = Diagnostic Support Service; OC = Obstetric Center; DH = Day Hospital; CPC = Center for Psychosocial Care.

** % calculated from the total of 416 sectors.

Note: (N=416).

DISCUSSION

The NP documentation is a formal requirement in Brazil7 , 18 - 19 and should be done in all sectors where nursing care is provided to the users, which is considered necessary to improve the quality of care7 and to evidence the quality of nursing care21 . The results of this study have enabled learning about the nursing documentation situation in hospitals and outpatient clinics under direct administration of SES/SP almost 10 years after the beginning of the Tecendo SNC Project5 - 6 .

The scope of this study can be evaluated considering the participation of 40 (93%) of the 43 eligible institutions. In Table 1 we see that more than 85% of the total of each modality from the sectors where nursing professionals worked in the health institutions under study were evaluated, and in some cases all were covered. Thus, we understand that the results of this study consistently portray the situation of the healthcare units managed by SES/SP in relation to the NP implementation at the time.

Of the 416 sectors studied, almost all of them document at least one NP phase, with 24 (5.8%) not doing any NP documentation, not even nursing annotations ( Table 2 ).

It was not the objective of this study to clarify the reasons why the sector does not document the NP, nor is it possible to compare these results with data from other institutions, but the reasons are probably derived from the difficulties of implementing NP documentation which are already described in the literature3 , 10 , 14 - 16 . Without this documentation it is not possible to systematically recover what is being done by the nurses to users in these sectors. The result that the ambulatory, diagnostic support, surgical and obstetrical centers are the largest proportions of sectors that do not make any documentation on the patient’s chart ( Table 2 ) suggests that there are peculiarities in the nursing work or in the characteristics of the users of these types of sectors that need to be carefully studied against COFEN regulations on the subject18 - 19 .

Nursing annotation is documentation done even in institutions where the NP is not implemented, and the lack of this record draws attention, especially if the nursing team is composed of other professionals besides nurses. The observations of nursing technicians and assistants are recorded in the notes.

If we consider only the four phases of proper documentation to the NP (data collection, diagnosis, prescription and evaluation), the data in Table 2 show that the frequencies of sectors that document them vary from 78.8% (data collection and diagnostics) to 87.0% (evaluation). Data collection (physical examination/interview) is a procedure which enables obtaining the information to identify patient changes which need the nurses’ attention and was one of the least documented NP phases (78.8%) together with the diagnosis (78.8%) ( Table 2 ). Failure to perform the physical examination/interview by the nurse makes it difficult to adequately address the problems faced by the patient and to evaluate the obtained results with the prescribed/performed interventions. Failure to register this step hinders subsequent evaluations, the permanence or exclusion of diagnoses, prescription changes and nursing evolution. This phase is considered essential for the other NP phases, requires scientific knowledge, and must be reinforced with continuing education actions for nurses22 and must be documented18 . Documentation of patient assessment and conclusions from the assessment (diagnose) data is still the most fragile element of NP23 .

The means for the number of phases documented by sector type ( Table 2 ) show that ICUs are the sectors that most approached the five documentation categories with an average of 4.9, followed by hospital wards (4.6), the centers for psychosocial care (4.3), the obstetric centers (4.2) and the day hospitals (4.2). This result reinforces the previous observation that the sectors which work with non-hospitalized users (external users) are those that least document the NP or make nursing annotations: diagnostic support (mean of 2 phases); ambulatory (average of 3 phases); and emergency room (mean of 3.6 phases). The surgical center sectors had an average of 3.5 phases, which is justified by the relatively short time that the user stays in this sector that contributes to exacerbate difficulties in adhering to the rules of professional practice regarding clinical documentation.

The data in Table 3 show that the combinations of documented phases are quite varied. There are units which only document one NP phase or just the nursing annotations to units which document the four NP phases in addition to the nursing annotations. The sum of the totals for the lines in Table 3 , “DC, ND, NPR, NE, NA” and DC, ND, NPR, NE” represent the proportion of sectors that perform complete NP (69.3%). In a study carried out in 2004 in the SES/SP institutions located in the greater São Paulo area, but only part of the institutions of the present study, it was observed that 70% to 100% of the sectors in nine (24.3%) of the 37 institutions studied documented the four NP phases (data collection, diagnosis, prescription and evaluation)6 . From Table 3 , we can calculate that 56.0% of all the participating sectors – 233 sectors (156 GA; 48 ICU; 29 ER) from a total of 416 sectors – documented the four NP phases also studied in 20046 . It is not possible to make an unequivocal statement as to why the two studies had different coverage – that of 2004 was in the greater São Paulo area6 , and this study was statewide, but the results of the present study enable us to admit that there was an increase in the frequency of sectors with documentation of all phases between 2004 (24.3%) and 2012 (56.0%), validating the nursing efforts of SES/SP to improve nursing documentation5 . It is important to note that the number of institutions under direct administration of SES/SP is variable over time, which is why there were 37 institutions alone in the greater São Paulo area in 2004; a total very close to the total that was in the entire state of São Paulo in 2010-2012.

Table 3 – Positive reports of documentation by sets of NP phases and sector types – São Paulo, SP, Brazil, 2011-2012. 

Sets of NP phases * Sector types** Total

GA AB ICU ER SC DSS OC DH CPC

n % n % n % n % n % n % n % n % n % n %
DC, ND, NPR, NE, NA 156 77.6 21 36.8 48 92.3 29 82.9 7 31.8 2 11.1 11 68.8 6 66.7 4 66.7 284 68.3
ND, NPR, NE, NA 24 11.9 1 1.8 3 5.8 - - 2 9.1 - - 1 6.3 - - - - 31 7.5
None 1 0.5 13 22.8 - - 1 2.9 1 4.5 7 38.9 1 6.3 - - - - 24 5.8
Only notes 3 1.5 6 10.5 - - 2 5.7 2 9.1 4 22.2 - - 1 11.1 - - 18 4.3
NE, NA 4 2.0 3 5.3 - - 1 2.9 2 9.1 1 5.6 1 6.3 - - - - 12 2.9
DC, NPR, NE, NA 2 1.0 2 3.5 - - 1 2.9 1 4.5 2 11.1 - - 1 11.1 - - 9 2.2
DC, NE, NA 2 1.0 3 5.3 - - - - 3 13.6 - - - - - - - - 8 1.9
DC, NPR, NE - - 1 1.8 - - - - 2 9.1 1 5.6 1 6.3 - - 1 16.7 6 1.4
DC, ND, NE, NA 3 1.5 2 3.5 - - - - - - - - - - - - - - 5 1.2
NPR, NE, NA 2 1.0 - - 1 1.9 - - - - - - - - 1 11.1 - - 4 1.0
DC, ND, NPR, NE 2 1.0 2 3.5 - - - - - - - - - - - - - - 4 1.0
DC, NA - - 2 3.5 - - - - - - - - 1 6.3 - - - - 3 0.7
DC 1 0.5 1 1.8 - - 1 2.9 - - - - - - - - - - 3 0.7
ND, NPR, NA - - - - - - - - 1 4.5 - - - - - - 1 16.7 2 0.5
NPR, NA - - - - - - - - - - 1 5.6 - - - - - - 1 0.2
DC, ND, NPR, NA - - - - - - - - 1 4.5 - - - - - - - - 1 0.2
ND, NPR, NE 1 0.5 - - - - - - - - - - - - - - - - 1 0.2

Total 201 100 57 100 52 100 35 100 22 100 18 100 16 100 9 100 6 100 416 100

* DC – data collection (history and physical examination); ND - nursing diagnosis; NPR - nursing prescription; NE - nursing evaluation; NA - nursing annotations. The annotation was only included as the NP phase to facilitate the presentation of the results.

** GA = General Admission for hospitalization; AB = Ambulatory; ICU = Intensive Care Unit; ER = Emergency Room; SC = Surgical Center; DSS = Diagnostic support service; OC = Obstetric center; DH = Day Hospital; CPC = Center for Psychosocial Care. Note: (N = 416).

It is worth mentioning the line in Table 3 which presents the sectors that did not perform any NP stage, considering that the nursing annotations was one of the alternative responses. The results of the diagnostic support and outpatient sectors, in which 38.9% and 22.8%, respectively, did not register any nursing annotations ( Table 3 ). We believe that in sectors where care is provided with little contact time between users and nursing by their very nature, the documentation of all NP phases needs to be discussed. However, this is not the case in other sector types in which no record is made, as in one case (0.5%) which occurred in the hospitalization sector; one (2.9%) in the emergency room; one (4.5%) in the surgical center; and one (6.3%) in the obstetric center ( Table 3 ). In these sectors, the length of stay and the degree of care complexity require documentation from the NP as a way to guarantee care continuity and provide safety for professionals and patients18 - 19 , even if the applicability of the documentation is questioned for all stages. The absence of registration disregards legal precepts, biases the research, favors care discontinuation and makes the nurse’s role less visible24 . However, it is necessary to know the contexts and the reasons why the absence of nursing records still occurs.

Of the sectors that registered all NP stages, the ICU stood out with 92.3% and the emergency room with 82.9% documentation of all the NP stages ( Table 3 ). This proportion in the emergency room was greater than we expected, as it is often considered unfeasible to document the NP in emergency or emergency sectors20 , 25 . We did not find a study that would allow us to compare results with those of this study regarding documentation in the ICU sectors. However, it is believed that some explanations for this fact can be considered: the sector receives more unstable patients with more risk procedures; there is a nurse/patient relationship that is more favorable to the records, and perhaps the ICU nurse more clearly perceives their clinical role in patient care; and that accurate recording is a relevant factor to ensure safer care for the patient and the professional.

Implementation of NP documentation requires that the engagement of those involved be based on the firm foundation that actions stemming from the clinical role of nursing influence the health outcomes of people26 . The idea that nurses resist the use of NP is common because they have difficulty adopting it in their practices3 , 10 , 16 , 20 . However, if nurses do not recognize that they have a clinical role with health service users, that their care actions influence the health of the people, there will be no preparation that will reduce their resistance to using the NP or institutional policies capable of incorporating models compatible with the use of NP.

Absence of documentation or inadequate documentations may result in: care discontinuation, inadequate evaluation of changes in the patient’s clinical condition, inaccurate judgment of results, lack of a consistent legal basis for advocacy for work performed or care received.

The results of this study allow us to discuss whether the NP phases and the nursing annotations are documented in the institution sectors of the SES/SP, but no inference is possible on the documented contents and to what extent they reflect the nursing that is offered to the users of these services. In any case, it is necessary that the reasons for non-compliance of some sectors with the determinations of COFEN19 be identified, so that ways to further improve the clinical documentation of nursing in health services may be found.

CONCLUSION

There are undoubtedly situations that need to be corrected with regard to NP documentation in institutions under the direct management of SES/SP. However, this study has shown that most sectors document NP and make nursing annotations. Of course, this situation has to do with the formal requirement of documentation, and especially with the incentive and support program to implement the NP adopted by SES/SP.

We cannot affirm that the results of this study represent what happens in all hospitals and clinics in the state of São Paulo. However, it is plausible to extrapolate the results that indicate that the sectors in which the contact time with the user is reduced are those that have less compliance with the documentation requirements for the majority of health institutions. The sectors that document the least are those for outpatient care. Considering that the contact time for the necessary care may be quite short in these cases, it is necessary to discuss how to operationalize the documentation of all the NP stages in these sectors.

The main limitation of this study refers to the data obtained by nurse reports, and not by direct observation. As the matter involves formal requirement of an overseeing body, the risk of bias should be considered. Another aspect is that the results of this study do not enable estimating how much time the user has documented NP, being considered from the entrance in the nursing care system until the exit. These observations, among others, support the need to develop ways of not only estimating the presence of NP documentation, but also the degree of coverage in relation to the entire period that the user remains in the nursing care system.

The development of documentation indicators that can be shared between different sectors with different service types is necessary to monitor the conformity of services with the formal requirement of NP documentation. There are aspects of NP documentation related to the relevance, clarity, consistency and accuracy of what is documented that go far beyond the aspects related to its presence and coverage degree.

REFERENCES

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Financial support Part of the project was financed by the Conselho Nacional de Desenvolvimento Científico e Tecnológico ( CNPq ), Process #481728/2009-0, and the Fundação de Amparo à Pesquisa do Estado de São Paulo ( FAPESP ), Process #2010/02985-6.

Received: March 26, 2018; Accepted: March 14, 2019

Corresponding author: Oswalcir Almeida de Azevedo Estrada de Itapecerica, 5859 – Jardim IAE CEP 05859-001 – São Paulo, SP, Brazil oswalcir@terra.com.br

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