Effect of an educational program on the quality of Nursing Process recording

Abstract

Objective: To verify the effect of an educational program on the quality of nursing process recording. Method: Quasi-experimental study comparing the quality of records in medical charts according to the version adapted for use in Brazil of the instrument Quality of Nursing Diagnoses, Interventions and Outcomes. The instrument was applied before and after four educational meetings with nurses of the clinic units of a hospital, conducted between 2015 and 2016. The intervention was based on the use of an instrument with standardized language systems for diagnoses, interventions and outcomes, discussed based on real clinical situations. The data were organized and analyzed using the software Statistical Package for Social Science (SPSS), version 20.0, considering as signifi cant p<0.05. Results: The mean total score regarding the quality of nursing records presented signifi cant improvement (p = 0.003), and the dimensions "Nursing Diagnoses as Process", "Nursing Diagnoses as Product" and "Nursing Outcomes" presented improvement, but their scores remained low. Conclusion: The intervention was effective in improving the quality of nursing records, proving the need for educational programs for the implementation of standardized language systems in hospital practice, which should guide the diagnostic reasoning and the decision-making process of nurses.