Qualidade das anotações de enfermagem em unidade de terapia intensiva de um hospital universitário

Abstract

Nursing notes are sources of information that allow for multiprofessional communication. The objective of this study was to evaluate the quality of the nursing notes in the intensive care unit of a university hospital. A descriptive-quantitative study was performed utilizing secondary data collection from quality assessment records of nursing notes from 2009. The report results were compared according to the following criteria: complete, incomplete, blank and incorrect, considering, respectively, a satisfactory score of more than 80%, below 15%, less than 5%, and 0%. Satisfactory scores were found for cases involving at least one note per shift and including pre and post-operative care/exams. There was a reduction in the scores for signs and symptoms, complications and response to the nursing care. Regarding textual esthetics, results were unsatisfactory for author identification and item checklists. Results revealed several inadequacies, proving the need for educational measures, and the improvement of nurses' skills and service. Descriptors: Nursing; Nursing Care; Quality Management; Nursing Records. (English) [ABSTRACT FROM AUTHOR]