Nursing records in pediatric intensive care units: a descriptive study

Abstract

Continuity  of  care  depends  on  the  sharing  of  information between professionals,  which  occurs  mainly  through  completion  of  patient  records.  Failure  to transmit  or  receive  messages  may  result  in  risks  to  patient  safety  and  reflect  on  the quality  of  care  provided.  Aim:  To  verify  whether  the  nursing  records  in  the  medical records  of  patients  hospitalized  in  Unidades  de  Terapia  Intensiva  Pediátrica  (UTI-P - Units  of  Pediatric  Intensive  Care)  correspond  to  the  safety  needs  recommended  in  the literature.  Method:  This  is  a  descriptive  and  quantitative  study,  through  documentary research  in  the  nursing  records  of  92  medical  records,  in  three  UTI-P.  Results:  It  was found  that  in  21.8%  of  the  records  there  were  erasures  and  in  26.1%  there  was  no complete identification of the care professional. Discussion: Records should not present erasures,  as they  make  it  difficult  to  plan  care.  In  addition,  professionals  must include their  name  and  registration  number  at  the  end  of  the  information  noted.  Conclusion: Records  were  adequate  according  to  the  safety  recommendations,  although  some aspects are still lacking in relation to nursing standards.