Abstract
Objective: to analyze the quality of the nurses' records performed in a pediatric inpatient unit.Method: a descriptive and cross-sectional study, of the documentary analysis type. An audit was carried out between July and October 2019, extracting data referring to the assistance through the quality of the nurses' records. The data were analyzed by means of ab in addition to calculation of the Positivity Index Results: a total of 1,129 records made by the nurses in the medical records of 67 children and adolescents were analyzed. The records varied in their classification between adequate, safe, borderline, and deficient. In the general context, the records reflected deficient care, since they were not classified as of quality. Conclusion: the nurse's record evidenced gaps in the care provided to the pediatric population, evidencing the need to expose the magnitude of the theme to the directly involved professionals, aiming at improving care quality.
References
Adereti CS, Olaogun AA. Use of electronic and paper-based standardized nursing care plans to improve nurses’ documentation quality in a nigerian teaching hospital. Int J Nurs Knowl [Internet]. 2019 [Cited 2019 jun 15];30(4):219–27. Available from: https://pubmed.ncbi.nlm.nih.gov/30525306/ doi: 10.1111/2047-3095.12232
González-Samartino M, Delgado-Hito P, Adamuz-Tomás J, Cano MFV, Creus MC, Juvé-Udina M-E.
Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase. Rev da Esc Enferm da USP [Internet]. 2018 [Cited 2019 jun 15]; 52:1–7. Available from: ttps://www.scielo.br/scielo.phpscript=sci_arttext&pid=S0080-62342018000100406 doi:10.1590/s1980-220x201701120330
Linch GFC, Lima AAA, Souza EN, Nauderer TM, Paz AA, Costa C. An educational intervention impact on the quality of nursing records. Rev Latino-Am Enfermagem [Internet]. 2017 [Cited 2019 jun 15] ; 25:(e2938). Available from: https://www.scielo.br/pdf/rlae/v25/0104-1169-rlae-25-e2938.pdf Doi: 10.1590/1518-8345.1986.2938
Lindberg MH, Venkateswaran M, Khader KA, Awwad T, Ghanem B, Hijaz T, et al. ERegTime, efficiency of health information management using an electronic registry for maternal and child health: Protocol for a time-motion study in a cluster randomized trial. J Med Internet Res [Internet]. 2019 [Cited 2019 jun 15]; 21(8):1–15. Available from:
https://www.researchprotocols.org/2019/8/e13653/ doi: 10.2196/13653
Mihaljevic AL, Schmidt J, Mitzkat A, Probst P, Kenngott T, Mink J, et al. Heidelberger interprofessionelle ausbildungsstation (HIPSTA): a practice-and theory-guided approach to development and implementation of germany’s first nterprofessional raining ward. GMS J Med Educ [Internet]. 2018 aug [Cited 2019 jun 15]; 35(3):1–22. Available from: https://pubmed.ncbi.nlm.nih.gov/30186943/ doi: 10.3205/zma001179
Cabero MJ, Guerra JL, Gaite L, Prellezo S, Pulido P, Álvarez L. La experiencia de implantar la norma ISO 9001:2015 para certificar una unidad hospitalaria de urgencias pediátricas. J Healthc Qual Res [Internet] . 2018 [Cited 2019 jun 15] ;33(4):187-92. DOI: 10.1016 / j.jhqr.2018.02.005
Conselho Federal de Enfermagem. Guia de recomendações para registros de enfermagem no prontuário do paciente e outros documentos de enfermagem [e-book]. Brasília: COFEN; 2016. [cited 2020 nov 17]. Available from: http://www.cofen.gov.br/wp-content/uploads/2016/06/RESOLU%C3%87%C3%83O-COFEN-N%C2%BA-0514-2016-GUIA-DE-RECOMENDA%C3%87%C3%95ES-vers%C3%A3o-web.pdf
Haddad MCL, Évora YDM. Qualidade da assistência de enfermagem: a opinião do paciente internado em hospital universitário público. Ciênc Cuid Saúde [Internet]. 2009 [Cited 2019 jun 15]; Suplem. 1:45-52. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/6559 doi: https://doi.org/10.4025/cienccuidsaude.v7i0.6559
Saupe R, Horr L. Auditoria em enfermagem. Rev Ciênc Saúde. 1982;1(1):23.
Cianciarullo Ti, Fugulin Fmt, Andreoni S. C & Q: teoria e prática em auditoria de cuidados. São Paulo: Ícone; 1998. 197p.
Horta WA. Processo de enfermagem. São Paulo: EDUSP; 1979. 99 p.
Carneiro SM, Dutra HS, Costa FM, Mendes SE, Arreguy-Sena C. Uso de abreviaturas nos registros de enfermagem em um hospital de ensino. Rev Rene [Internet]. 2016 [Cited 2019 jun 15];17(2):208-16. doi: 10.15253/2175-6783.2016000200008
Parente JSM, Silva FRA. Perfil clínico-epidemiológico dos pacientes internados na clínica pediátrica em um hospital universitário. Rev Med da UFC [Internet]. 2017 [Cited 2019 jun 15]; 57(1):10. Available from: http://periodicos.ufc.br/revistademedicinadaufc/article/view/19819
Souza VR, Queluci GC, Soares RS, Mendonca AR, Dias SFC. Checklist of Physical Examination: contributions to the teaching of the Fundamentals of Nursing. Rev Enferm Atual [Internet]. 2018 [cited 2019 Jan 18]; 86:1–8. Available from: https://revistaenfermagematual.com.br/index.php/revista/article/view/75/386
Teixeira CC, Boaventura RP, Souza ACS, Paranaguá TTB, Bezerra ALQ, Bachion MM, et al. Vital Signs Measurement: an Indicator of Safe Care Delivered To Elderly Patients. Texto Contexto Enferm [Internet]. 2015 [cited 2019 Jan 18];24(4):1071–8. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072015000401071
Silva TG, Santos RM, Crispim LMC, Almeida LMWS. Conteúdo dos registros de enfermagem em hospitais: contribuições para o desenvolvimento do processo de enfermagem. Enferm Foco [Internet]. 2016 [Cited 2019 jun 15];7(1):24-7. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1028236
Conselho Federal de Enfermagem. Resolução COFEN n. 311, de 8 de fevereiro de 2007. Aprova a reformulação do código de ética dos profissionais de enfermagem [Internet]. Diário Oficial da União, Brasília (DF); 2007 Nov 17 [cited 2020 nov 17]. Available from: http://www.cofen.gov.br/resoluo-cofen-3112007_4345.html
Ferreira LL, Chiavone FBT, Bezerril MS, Alves KYA, Salvador PTCO, Santos VEP. Análise dos registros de técnicos de enfermagem e enfermeiros em prontuários. Rev Bras Enferm [Internet]. 2020 [cited 2020 nov 17];73(2):e20180542. Available from: https://www.scielo.br/scielo.php?pid=S0034-71672020000200156&script=sci_arttext&tlng=pt
Mena LS, Silva RC, Porto AR, Zillmer JGV, Barcellos CRB. Peripherally inserted of central catheter of in neonatology: potentials and fragilities according to nurses’ perspective. Ciênc Cuid Saúde [Internet]. 2019 [cited 2020 nov 17];18(4):0–3. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1120020
Vieira GLC, Campos IML, Fernandes BS, Ladeira AG, Pimenta EF. Falls among children and teenagers in hospitals: an integrative literature review. RECOM. 2019; 9(e2709):1–9. doi: 10.19175
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Copyright (c) 2020 Array