"Análise dos registros de enfermagem em uma unidade cirúrgica de um hospital escola" / Analysis of nurse’s notes in a school hospital surgical ward

AUTOR(ES)
DATA DE PUBLICAÇÃO

2005

RESUMO

Written communication in Nursing has displayed crucial importance in care continuity administered to the patient in order to improve the quality of the assistance given by the nursing professionals. It is a descriptive and retrospective research with a quantitative approach that attempts to classify the notes content according to the psychobiological, psychosocial and psychospiritual needs and to identify the professional category responsible for the notes and the number of notes at each work shift. The sample consisted on notes made by the nursing team on records of male patients registered into the gastric and the urinary wards in a school hospital from September 1st to October 31st, 2003. According to the inclusion criteria, 62 records were selected including 1,448 notes made by the nursing team. Results showed that 35.0% were made during the morning, 33.4% during the afternoon and 31.6% at night. Auxiliary nurse was the professional category with higher rates of notes production accounting for 97.7%, followed by the registered nurses with 2.9%. The psychobiological need accounts for 68.2% of the notes and the psychosocial need sums up 31.8%. The psychospiritual need wasn’t mentioned in any of the analyzed notes. As a conclusion, the nurse’s notes must be improved and entirely composed to guarantee the quality in the assistance given to the patient.

ASSUNTO(S)

registros de enfermagem comunicação nurse’s notes necessidades básicas communication basic needs

ACESSO AO ARTIGO

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