Dados essenciais em enfermagem nos formulários das clínicas de infectologia: estudo comparativo.

Abstract

Nursing records, which are in the documentation of assistance provided to the client, have evolved over the years, of manuals to check-lists and, subsequently, computerized, so that facilitates the professional practice, reduces the time required and improved its quality. In addition to informing the assistance provided, they allow the care is continued, based on the diagnosed problems, interventions and planned results. However, one of the major problems that nursing is the lack of universal standardization of record, a fact that shows the need for the profession to adopt an instrument, which shows the population, organized the quality of care. The International Set of mission-critical data in nursing is an instrument consisting of minimum elements to be collected from the customer, with the objective of structuring and standardizing the collection of elements. In view of the importance of an appropriate instrument for the achievement of a good registry data, rose the following question: is it possible to analyze the data present in forms of documentation used by nursing staff of three infectious diseases clinics hospitals references in the State of Paraiba. Objectives: This study aimed to categorize the data present in forms of documentation used by nursing staff of infectious diseases clinics of three hospitals in the State of Paraiba references and compare them with the model proposed by the International Set of Essential nursing Data (i-NMDS). Methodology: This is a descriptive and comparative nature research with qualitative approach, developed in clinics of infectious diseases of hospitals in the State of Paraiba references: University Hospital Alcides Carneiro - HUAC, University Hospital Lauro Wanderley - HULW and Dr. Clementino Fraga hospital complex - HCF, divided into three steps: Categorisation of documentation forms used by nursing staff and identification of critical data, comparison of data found with the proposed International Minimum Data Set for nursing and analysis of the data found in accordance with the literature of the area. Results: Of the 17 items of i-NMDS compared to instruments used in infectious diseases clinics of Paraíba, obtained a total of 11 similar items in the instrument of HUAC and HULW, corresponding to 64.71% of what is proposed, and the instrument of the HCF, 5 of the elements were contemplated, characterizes 29.41% than is recommended So, it was realized that the tools used were a large part of what is proposed, however, requires some adjustments to that collection and data records are made of the most appropriate form and embase nursing care. Conclusion: The study brought contributions to nursing care in Infectology, because it was possible to identify essential items to the appropriate record of care, facilitate the nursing documentation and, consequently, communication, ethical and legal support on the quality of care. It should be noted, moreover, the contribution to the scientific community, since it was demonstrated the use of standardization of international language, as well as the possibility of developing subsequent studies, therefore, the data make it possible to draw up an instrument that includes items proposed by i-NMDS to guide nursing practice in infectious diseases.