Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

Nomura, Aline Tsuma Gaedke; Silva, Marcos Barragan da; Almeida, Míriam de Abreu

doi:10.1590/1518-8345.0686.2813

Cited by 38 publications

(48 citation statements)

References 17 publications

(30 reference statements)

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“…NCS use is crucial to the provision of a safe nursing care, as it provides nurses with technical, scientific and human resources, improves the quality of care provided to the client and enables the recognition and appreciation of nursing in society (3)(4)(5)(6) . Thus, in addition to collaborating for a safe nursing care, NCS and NP integration, once implemented and performed properly, collaborate to carry out academic research, legal analysis, auditing of accounts and general analysis of levels of quality of care of nursing (7) .…”

Section: Introductionmentioning

confidence: 99%

Nursing care systematization: perceptions and knowledge of the Brazilian nursing

et al. 2019

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Objective: to present the perception and knowledge of Brazilian nursing nurses and academics regarding Nursing Care Systematization. Method: a descriptive study, carried out in the first half of 2018. Results: of the 596 respondents, 86% perceived Nursing Care Systematization as very important, but only 60.9% used it in their care practice. Its use was statistically associated with a higher level of training. Non-utilization was associated with the perception that it is irrelevant and with little knowledge on the Nursing Process, even in the face of recognition of its obligation. Among professionals who wish to learn more about the subject, understanding the application of the process, especially the planning step, is perceived as a necessity. Conclusion: the relevance perception of systematization and levels of knowledge of the professional/academic are directly related to the use or not of Nursing Care Systematization principles.

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Section: Introductionmentioning

confidence: 99%

Nursing care systematization: perceptions and knowledge of the Brazilian nursing

et al. 2019

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“…A Brazilian study analyzed the quality of nursing records before and after hospital accreditation. Among the data evaluated, it was possible to identify that the dimension "Nursing Diagnoses as Product" did not present differences before and after intervention (p=0.002) (20) . However, in this study, all items showed improvement after the intervention (p=0.006).…”

Section: Discussionmentioning

confidence: 97%

“…A significant improvement in the quality of nursing records was observed in 24 of the 29 items (82.8%) of the questionnaire. (20) The institution maintains the study group as a continuous strategy to improve the quality of nursing records, the Nursing Process and standardized language systems in electronic medical records.…”

Section: Discussionmentioning

confidence: 99%

Efeito do programa educativo na qualidade do registro do Processo de Enfermagem

et al. 2019

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Objective: To verify the effect of an educational program on the quality of nursing process recording. Method: Quasi-experimental study comparing the quality of records in medical charts according to the version adapted for use in Brazil of the instrument Quality of Nursing Diagnoses, Interventions and Outcomes. The instrument was applied before and after four educational meetings with nurses of the clinic units of a hospital, conducted between 2015 and 2016. The intervention was based on the use of an instrument with standardized language systems for diagnoses, interventions and outcomes, discussed based on real clinical situations. The data were organized and analyzed using the software Statistical Package for Social Science (SPSS), version 20.0, considering as signifi cant p<0.05. Results: The mean total score regarding the quality of nursing records presented signifi cant improvement (p = 0.003), and the dimensions "Nursing Diagnoses as Process", "Nursing Diagnoses as Product" and "Nursing Outcomes" presented improvement, but their scores remained low. Conclusion: The intervention was effective in improving the quality of nursing records, proving the need for educational programs for the implementation of standardized language systems in hospital practice, which should guide the diagnostic reasoning and the decision-making process of nurses. ResumoObjetivo: Verifi car o efeito de um programa educativo na qualidade dos registros do processo de enfermagem. Métodos: Estudo quase-experimental, que comparou a qualidade de registros nos prontuários considerando a versão adaptada para uso no Brasil do Quality of Nursing Diagnoses, Interventions and Outcomes antes e após quatro encontros educativos realizados com enfermeiros de unidad es de clínica médica de um hospital de grande porte, entre 2015 e 2016. A intervenção teve como base o uso de um instrumento com sistemas de linguagens padronizadas de diagnósticos, intervenções e resultados, discutido a partir de situações clínicas reais. Os dados foram organizados e analisados com auxílio do software Statistical Package for Social Science (SPSS), versão 20.0, considerando signifi cativo p< 0,05. Resultados: A média do escore total da qualidade dos registros de enfermagem melhorou signifi cativamente (p=0,003), e as dimensões "Diagnóstico de Enfermagem como Processo", "Diagnóstico de Enfermagem como Produto" e "Resultados de Enfermagem de Enfermagem", melhoraram suas médias, apesar de permanecerem baixas. Conclusão: A intervenção foi efetiva na melhora da qualidade dos registros de enfermeiros, comprovando a necessidade de programas educativos para implementação de sistemas de linguagens padronizadas na prática hospitalar, que direcionem o raciocínio diagnóstico e a tomada de decisões por enfermeiros. ResumenObjetivo: Verifi car el efecto de un programa educativo en la calidad de los registros del proceso de enfermería. Métodos: Estudio cuasi experimental, que comparó la calidad de los registros en las historias clínicas considerando la versión adaptada para Brasil del...

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“…A documentação em prontuário destacou-se como uma prática essencial ao enfermeiro, tendo importância clínica e legal e constituindo-se em importante ferramenta de comunicação entre os profissionais de enfermagem e da saúde. No cuidado da pele, cabe ao enfermeiro e equipe realizarem registros que reflitam a assistência ao paciente de forma clara, completa e fidedigna, de forma a garantir continuidade, segurança e qualidade do cuidado (6,(12)(13) .…”

Section: Discussionunclassified

<b>Atuação do Enfermeiro na terapêutica por pressão negativa a paciente com lesão de grande extensão / Nurse's activity in negative-pressure wound therapyin patient with a large injury<b>

Martins¹,

Kaiser²,

Bittencourt³

et al. 2019

Cienc. Cuid. Saúde

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O objetivo do estudo foi conhecer a atuação do enfermeiro na terapêutica por pressão negativa a paciente com lesão de grande extensão.Trata-se de estudo de caso único desenvolvido em um hospital geral de médio porte, interior do estado do Rio Grande do Sul, Brasil. A coleta de dados deu-se por meio de consulta a registros e imagens documentados em prontuário e entrevista semiestruturada realizada com profissionais da equipe interdisciplinar, diretamente envolvidos com o caso, ocorrido no ano de 2016. Do corpus da análise resultaram três categorias: o caso João; articulação das ações do enfermeiro com a equipe interdisciplinar em prol do cuidado; a terapêutica por pressão negativa. A atuação do enfermeiro configura-se como estratégica na promoção do cuidado da pele na terapêutica por pressão negativa, capaz de sensibilizar, estimular e articular a equipe para a efetivação de um trabalho integrado, seguro e de qualidade à pessoa com lesão.

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Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

Cited by 38 publications

References 17 publications

Nursing care systematization: perceptions and knowledge of the Brazilian nursing

Nursing care systematization: perceptions and knowledge of the Brazilian nursing

Efeito do programa educativo na qualidade do registro do Processo de Enfermagem

<b>Atuação do Enfermeiro na terapêutica por pressão negativa a paciente com lesão de grande extensão / Nurse's activity in negative-pressure wound therapyin patient with a large injury<b>

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