Nurses Records in Medical Records of a School Hospital

Abstract

Objective: Describe the characteristics of the evolution of nurses in the medical records of patients admitted to a school hospital in the city of João Pessoa, PB, Brazil.Methods: This is a descriptive, exploratory and documental, embodied in a quantitative approach. The source of study data were the records of patients of the Pediatric Clinic of Infectious and Parasitic Diseases (IPD), who were in the Statistical and Medical Archive Service (SMAS), in a time frame from April to October 2015. The analysis the data was performed, from the descriptive statistics, using a statistical software.Results: Through the data collected, two characteristics were observed in the records: the general aspects and the focus of care. In general aspects, the developments were characterized as being absent from erasures, use of correctives, grammatical errors, non-standard abbreviations and generic terms. They proved to be legible and clear, using scientific terminology, the date and time stamp. However, it was found that there are many blanks. As the focus of care, the records contemplated the general condition, level of consciousness, respiratory pattern and eliminations.Conclusions: Based on the foregoing, the concreteness of this study shows us that nurses need to be aware in order to provide a more qualified registration and, above all, standardized, ensuring continuity of care and promoting the evaluation of the implemented care.