Analysis of records by nursing technicians and nurses in medical records
ABSTRACT Objectives: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. Methods: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was...
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| Format: | Article |
| Language: | English |
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Associação Brasileira de Enfermagem
2020-02-01
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| Series: | Revista Brasileira de Enfermagem |
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| Online Access: | http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672020000200156&tlng=en |
| _version_ | 1818988868160978944 |
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| author | Larissa de Lima Ferreira Flávia Barreto Tavares Chiavone Manacés dos Santos Bezerril Kisna Yasmin Andrade Alves Pétala Tuani Candido de Oliveira Salvador Viviane Euzébia Pereira Santos |
| author_facet | Larissa de Lima Ferreira Flávia Barreto Tavares Chiavone Manacés dos Santos Bezerril Kisna Yasmin Andrade Alves Pétala Tuani Candido de Oliveira Salvador Viviane Euzébia Pereira Santos |
| author_sort | Larissa de Lima Ferreira |
| collection | DOAJ |
| description | ABSTRACT Objectives: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. Methods: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records. Results: the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses’ records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%. Conclusions: the study showed that nursing professionals perform their records incompletely and often do not document the care provided. |
| first_indexed | 2024-12-20T19:29:25Z |
| format | Article |
| id | doaj.art-1f415d7eae084ac6880616fe0f8d641c |
| institution | Directory Open Access Journal |
| issn | 1984-0446 |
| language | English |
| last_indexed | 2024-12-20T19:29:25Z |
| publishDate | 2020-02-01 |
| publisher | Associação Brasileira de Enfermagem |
| record_format | Article |
| series | Revista Brasileira de Enfermagem |
| spelling | doaj.art-1f415d7eae084ac6880616fe0f8d641c2022-12-21T19:28:49ZengAssociação Brasileira de EnfermagemRevista Brasileira de Enfermagem1984-04462020-02-0173210.1590/0034-7167-2018-0542Analysis of records by nursing technicians and nurses in medical recordsLarissa de Lima Ferreirahttps://orcid.org/0000-0003-2567-2236Flávia Barreto Tavares Chiavonehttps://orcid.org/0000-0002-7113-2356Manacés dos Santos Bezerrilhttps://orcid.org/0000-0002-9003-2334Kisna Yasmin Andrade Alveshttps://orcid.org/0000-0001-7900-0262Pétala Tuani Candido de Oliveira Salvadorhttps://orcid.org/0000-0002-3208-6270Viviane Euzébia Pereira Santoshttps://orcid.org/0000-0001-8140-8320ABSTRACT Objectives: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. Methods: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records. Results: the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses’ records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%. Conclusions: the study showed that nursing professionals perform their records incompletely and often do not document the care provided.http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672020000200156&tlng=enNursingCommunicationNursing recordsPatient safetyHealth Services Research |
| spellingShingle | Larissa de Lima Ferreira Flávia Barreto Tavares Chiavone Manacés dos Santos Bezerril Kisna Yasmin Andrade Alves Pétala Tuani Candido de Oliveira Salvador Viviane Euzébia Pereira Santos Analysis of records by nursing technicians and nurses in medical records Revista Brasileira de Enfermagem Nursing Communication Nursing records Patient safety Health Services Research |
| title | Analysis of records by nursing technicians and nurses in medical records |
| title_full | Analysis of records by nursing technicians and nurses in medical records |
| title_fullStr | Analysis of records by nursing technicians and nurses in medical records |
| title_full_unstemmed | Analysis of records by nursing technicians and nurses in medical records |
| title_short | Analysis of records by nursing technicians and nurses in medical records |
| title_sort | analysis of records by nursing technicians and nurses in medical records |
| topic | Nursing Communication Nursing records Patient safety Health Services Research |
| url | http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672020000200156&tlng=en |
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