Neves Rinaldo de Souza, Shimizu Helena Eri
Universidade de Brasília, Programa de Pós-Graduação em Ciências da Saúde, Brasília, DF.
Rev Bras Enferm. 2010 Mar-Apr;63(2):222-9. doi: 10.1590/s0034-71672010000200009.
This study seeks to analyze the execution of the Infirmary Attendance Systematization Nursing stages through an exploratory, qualitative and retrospective approach. The retrospective analysis took place using 25 medic reports containing 25 historical reports, 12 diagnosis reports, 100 prescriptions and 100 nursing evolution reports. The results demonstrated the many difficulties the nurses faced to make Nursing Assistance Systematization operational. Although all Nursing Assistance Systematization stages were accomplished - historical, diagnosis, prescription, evolution and nursing - it was verified a larger frequency in filling prescription and historical related forms and a lesser one related with evolution and diagnosis related forms. In short, Nursing Assistance Systematization procedures still are fragmentized, showing the need to reorganize this attendance methodology attendance, and, above all, to invest in continuous nursing training to improve the customer care services quality.
本研究旨在通过探索性、定性和回顾性方法分析医务室出勤系统化护理阶段的执行情况。回顾性分析使用了25份医疗报告,其中包括25份历史报告、12份诊断报告、100份处方和100份护理进展报告。结果表明,护士在使护理协助系统化运作方面面临诸多困难。尽管所有护理协助系统化阶段——历史、诊断、处方、进展和护理——均已完成,但发现填写处方和历史相关表格的频率较高,而与进展和诊断相关表格的频率较低。简而言之,护理协助系统化程序仍然是碎片化的,这表明需要重新组织这种出勤方法,最重要的是,投资于持续的护理培训,以提高客户护理服务质量。