Avaliação dos aspectos éticos e legais dos registros de enfermagem

Abstract

The records or nursing notes are ways of written communication which should be clear and concise, once they register the assistance given to patients. This study aimed to identify the ethical and legal aspects of nursing records in situations when cardiopulmonary arrests followed by cardiopulmonary resuscitations are performed. Information was obtained from medical records of patients who passed away in a University hospital of Paraná State. This is a descriptive-retrospective study of the nursing records from patients’ medical records. Data collection was carried out in 2004 through a previously elaborated instrument. Data was stored and processed with help of the Epi Info Program, and after a descriptive analysis it was presented in a table format. It was studied 114 nursing records from medical records, of which 101 (88.6%) did not present the identification of the functional category nor the therapeutic measures taken by the staff. It was also found 103 (90.35%) records lacking information regarding procedures prescribed by the physician and carried out by the nursing staff, and 98 (85.96%) records lacking information concerning patients’ specific responses to the received therapeutic. Conclusively, the evaluated records were found to be deficient, not portraying the provided care, and remaining unsupported regarding ethical and legal aspects.