Information management and nursing records in primary care: a descriptive study

Dorquelina Augusta Maia Rodrigues de Oliveira1, Geilsa Soraia Cavalcanti Valente1
1Fluminense Federal University


This is a Professional Master’s dissertation project on Education in Health, Fluminense Federal University. Aims: to identify the work processes of professionals in the Primary Care context as regards the production and use of health records; to discuss the importance of information management in a healthcare setting and its relevance to the quality of nursing records. Method: this is a descriptive exploratory study using a qualitative approach of three healthcare units in the city of Rio de Janeiro. The subjects are 12 nursing professionals who operate in these units. Data will be collected by semi-structured interviews between December 2015 and January 2016, and will be processed using content analysis.

Descriptors: Education, Continuing; Health Information Management; Nursing Records.


After the implementation of the Sistema Único de Saúde (SUS) (Unified Health System), health information saw a major evolution in terms of the number and improvements associated with information technology. This has required the development of specific skills for its use and for the consequent production of knowledge which has to used in specific situations with a view to improving the health of the population(1). As the Basic Health Unit is one of the gateways to the health system, and the organizing strategy in terms of comprehensive care, it is clear that the accuracy and systematic registration of the relevant data, as well as any changes in information, are essential for putting into place processes that are intrinsic to health.

One of the factors identified as being a significant obstacle to the production of records is the education level difference between the various professionals involved in care, some of whom do not always receive adequate training, or are clear as to the usefulness of the data being collected. This statement reinforces the importance of the need for reflection in action with regard to the practice of record production, in order to characterize the health work processes, mainly on the part of professionals working in the area in question.

For a long time, it has been observed by many scholars in the field that the quality of nursing records is a subject of concern. However, there are non-conformities in the various dimensions of these records, thus reducing the potential value in terms of nursing actions and performance.


How can health information management influence the quality of health records and routine activities in a primary care setting?


Describe the work processes of Primary Care professionals in terms of the production and use of health records;

Discuss the importance of information management in health, and its relevance to the quality of nursing records.


This paper is based on the assumption that the debate regarding the management of information in primary care, contextualizing the quality of records as a negotiating tool in terms of the permanent training of professionals in their daily practice, is necessary in order to better organize work, and to identify the needs and health conditions of the population(2). It can be argued that education programs for nursing professionals should not be limited to particular health actions. It is clear that it is necessary to invest in continuing education in order to raise awareness in terms of the importance of nursing records. Quality information enables the production of the knowledge that is essential for decision making(3).


This is an exploratory-descriptive field research that uses a qualitative approach. The study will involve three type B health units. These are traditional in that they incorporate one or more ESF teams, which partially cover the area for which they are responsible, as laid down in the Coordination of Programmatic Actions 5.1 of the municipality of Rio de Janeiro. The healthcare population is composed of 12 assistants, 12 technicians, and 12 nurses, all active in three health units. The inclusion criterion is: to be an active professional for at least one year in the study setting. The exclusion criterion is the absence of the professional in the period of application of the research instruments. The data collection period will be between December 2015 and January 2016.

As a data collection technique, semi-structured interviews will be used, and they will be recorded on an MP4 player. Data processing will be made by thematic content analysis. This project was approved by the Ethics Committee of the Faculty of Medicine, Universidade Federal Fluminense (Fluminense Federal University) FM/UFF/HU Antonio Pedro - 5243 (CAAE: 37662314.4.0000.5243) and by the Ethics Committee of the Municipal Secretariat of Health of the State of Rio de Janeiro/SMS/RJ - 5279 (CAAE: 37662314.4.3001.5279), according to Resolution No. 466/12.


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  2. Carreno I, Moreschi C, Marina B, Hendges DJB, Rempel C, Oliveira MMC. Análise da utilização das informações do Sistema de Informação de Atenção Básica (SIAB): uma revisão integrativa. Ciênc. saúde colet. [Internet]. 2015 Mar [cited 2016 Jan 08]; 20(3):947-56. Available from:
  3. Barreto PA, Braga ALS, Andrade M. Evaluation of completeness of dengue records: exploratory study of compulsory notices. Online braz j nurs [Internet]. 2012 Dec [cited 2016 Jan 8]; 11 (3):829-47. Available from:

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Received: 02/10/2016 Revised: 03/23/2016 Approved: 03/23/2016