de Carvalho Cesar Junior Aparecido, Nogueira Maria Suely
Universidade do Norte do Paraná e Mestre pela Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo na área de concentração Enfermagem Fundamental.
Rev Gaucha Enferm. 2006 Dec;27(4):524-31.
This article presents a systematic descriptive and retrospective study on nursing notes on patients admitted to the surgical ward of a teaching hospital in Londrina, Paraná, Brazil, which aimed at their systematic analisys. Results show that the largest number of notes was made during the morning shift, and most of them were made by nurse auxiliaries. As to basic needs, psychobiological records were the most frequent, whereas there no psychospiritual records were found. It was concluded that nursing notes must be improved, and take into account integral care of patients.
本文对巴西巴拉那州隆德里纳市一家教学医院外科病房收治患者的护理记录进行了系统的描述性和回顾性研究，旨在对其进行系统分析。结果显示，记录数量最多的是早班期间，且大多数记录由助理护士完成。关于基本需求，心理生物学记录最为常见，而未发现心理精神记录。研究得出结论，护理记录必须改进，并应考虑对患者的整体护理。
