对护理技术员和护士在病历中的记录进行分析。
Analysis of records by nursing technicians and nurses in medical records.
机构信息
Universidade Federal do Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil.
出版信息
Rev Bras Enferm. 2020 Feb 17;73(2):e20180542. doi: 10.1590/0034-7167-2018-0542. eCollection 2020.
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.
目的
分析巴西纳塔尔市一家公立医院护理记录中的主要不规范情况。
方法
这是一项描述性、横断面研究，采用定量方法。该研究在医疗和外科病房的护理部门进行。样本由 2016 年 10 月至 12 月期间的 120 份住院患者病历组成。使用 2013 年 Microsoft Excel 软件以绝对频率和相对频率进行简单统计，对获得的数据进行制表和分析。采用帕累托图评估记录中的不规范情况。
结果
护理记录中的主要问题是缺少专业类别和护理委员会编号，这导致护理技术员记录中的不规范情况占 41.8%；对于护士记录，主要的不规范情况是缺少时间和难以辨认的字迹，占 61.2%。
结论
研究表明，护理专业人员的记录不完整，经常不记录提供的护理。
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