Cover Image

The quality of nursing records at a maternity hospital: a descriptive study

Danielle Lemos Querido, Ana Paula Vieira dos Santos Esteves, Viviane Saraiva De Almeida, Rita Bernardete Ribeiro Gueiros Bornia, Joffre Amim Júnior, Roberta Wagner Pereira da Silva

Abstract


Aim: To identify non-conformities related to nursing records; to present proposals for team training with regard to the quality of nursing records. Method: This is a descriptive study using a quantitative approach. The study uses data from medical records to be collected from November 2015 to June 2016. An instrument was developed to collect data and the notes described will be compared to expected annotation standards. The collected variables will be analyzed using descriptive statistics. Expected Results: Acknowledging the importance of nursing records and how it affects nursing staff.


Keywords


Anotações de Enfermagem; Materno-infantil; Prontuário

References


- Barra, DCC, SASSO, GTMD. Padrões de dados, terminologias e sistemas de classificação para o cuidado em saúde e enfermagem. Rev Bras Enferm [Internet] 2011 Dec [Cited 2015 mar 24]; 64(6):1141-1149. Available from: .

- Moreira NS. Análise das anotações de enfermagem de acordo com a Resolução 19196 do Conselho Federal de Enfermagem. Rev.Saúde.Com [Internet] 2011 [Cited 2015 mar 24]; 7(2): 88-99. Available from: http://www.uesb.br/revista/rsc/v7/v7n2a01.pdf.

- Linch GFC, Staub MM, Rabelo ER. Quality of nursing records and standardized language: literature review. Online braz j nurs [Internet] 2010 November [Cited 2015 Aug 24]; 9 (2): Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/3088.




DOI: https://doi.org/10.17665/1676-4285.20155366