Avaliação da qualidade dos registros de enfermagem em prontuários à luz do processo de enfermagem.

Abstract

Nursing, over the years, has sought to adapt their methods to the contemporary, through changes not only in the specialized technical skills, but also with improvements in basic technical and technological flexibility in structuring organizations and prioritizing goals and working tools. With that comes the nursing process, a strong ally of Nursing, since it is a methodological tool which organizes the care provided by nurses. In addition, the nursing process is the method used for planning and evaluation of care, and nursing record is part of this process. From the genesis of PE that has become possible to arrange services through the care system and evaluate the quality of patient care exercised. Accordingly, the objective of this research was to evaluate the quality of nursing records in the records of patients at the Hospital Alcides Carneiro, diagnosing weaknesses in the process of working through the review of nursing records. This is a descriptive, retrospective (to make use of medical records of patients who had been discharged) and documentary records performed by the nursing staff in the medical records of patients at this hospital. The sample consisted of 100 medical records of the Medical Clinic, and, through analysis, it was possible to know the nursing process and evaluate the institution's notes nursing report. This survey found deficiency in the execution of some phases and documentation of the same, in addition, it was noticed that the nursing notes of this hospital are not satisfactorily fulfilled, since the average of good results was not achieved in no evaluation. Thus, it can be concluded that implement a business process in a nursing service by means of a theoretical model, it is an arduous task. The difficulties that the nurse faces being linked to a university hospital are large and can only be circumvented through much effort, resilience and willingness to optimize their professional practice.