Azevedo Oswalcir Almeida de, Guedes Érika de Souza, Araújo Sandra Alves Neves, Maia Magda Maria, Cruz Diná de Almeida Lopes Monteiro da
Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem na Saúde do Adulto, São Paulo, SP, Brasil.
Universidade Nove de Julho, São Paulo, SP, Brasil.
Rev Esc Enferm USP. 2019 Aug 19;53:e03471. doi: 10.1590/S1980-220X2018003703471.
To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health.
A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations.
Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors.
Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.
确定圣保罗州卫生部管理的医院和门诊中护理程序文件记录的普及率。
通过对40家机构416个科室负责护理程序四个阶段（数据收集、诊断、处方和评估）及护理记录的护士进行访谈，开展一项描述性研究。
在所研究的416个科室中，89.9%记录了至少一个阶段；56.0%记录了四个阶段；4.3%仅记录了护理记录；5.8%未记录任何阶段，也未记录护理记录。记录较少的科室类型包括：门诊、诊断支持、手术中心和产科中心；记录最多的科室包括：重症监护病房、急诊室和住院病房。在78.8%的科室中，数据收集和诊断是记录最少的阶段。
大多数研究科室记录护理程序并进行护理记录，但存在一些科室的文件记录不符合正式要求。某些类型科室记录护理程序所有阶段的可行性需要进一步深入研究。
