GARCIA, G. S.; http://lattes.cnpq.br/9471737203059722; GARCIA, Giulianna Soares.
Résumé:
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.
