Quality of nursing records in a sector of the Public Hospital of the City of Oberá

Abstract

Background: records are the main source of information regarding the patient's situation, and should contain complete and accurate information, as they allow retrospective evaluation of the care and attention provided. Aim: to analyze quality indicators of nursing records in a sector of the Public Hospital of the City of Oberá (Misiones) in Argentina. Methods: a retrospective, descriptive design was used for this study. The study was carried out from October 2021 to February 2022. The sampling process consisted in the selection of the patients' medical records, which finally consisted of 195 nursing records. Results: in relation to the distribution of compliance with nursing records according to the dimensions, problems are denoted in the home record, complete Kardex record (Digital Medical History System RISMi) and complete record of nursing notes records. Conclusions: the evaluation of the quality of nursing records denoted that there are problems and weaknesses in terms of content, process and structure. The results of this study affirmed that nurses have failed to understand and apply the basic concepts of nursing diagnosis, planning, implementation and evaluation. This is alarming for the quality and effectiveness of nursing education, as well as for staff development and training programs for nurses.