Quality of nursing records in a hospital: audit
| Autor(a) principal: | |
|---|---|
| Data de Publicação: | 2021 |
| Outros Autores: | , , , , , , |
| Tipo de documento: | Artigo |
| Idioma: | por |
| Título da fonte: | Research, Society and Development |
| Texto Completo: | https://rsdjournal.org/index.php/rsd/article/view/18684 |
Resumo: | Objective to evaluate, through auditing, the effectiveness of nursing records in a public hospital in Goiás. Method This is a descriptive and analytical study, carried out on medical records of patients hospitalized in a public hospital in Goiás. hospital stay longer than five days in neonatal, pediatric and maternal intensive care units. For data analysis, we used the comparison of means of continuous variables through the Mann-Whitney test. Results it was verified that the inadequate filling of the medical records compromised the quality criteria, before and after the educational action. However, the means inherent to complete, incomplete and unfilled information in relation to medical records were significantly repaired after the educational action (p<0.05). The categories, identification data (PP=81.16%) and the execution of medical orders (PP=89.13%) had higher adequacy rates regarding complete records. The nursing prescription compromised the quality, regarding the incorrect filling of the records in (PP=6.76%). Conclusion nursing records do not meet the quality criteria, even after the educational action, considering that the effectiveness of the records underwent minor adjustments. It is recommended that educational actions be instituted in the hospital's health policies. |
| id |
UNIFEI_e02de64edc2cd5f6bec2fad65b8e34aa |
|---|---|
| oai_identifier_str |
oai:ojs.pkp.sfu.ca:article/18684 |
| network_acronym_str |
UNIFEI |
| network_name_str |
Research, Society and Development |
| repository_id_str |
|
| spelling |
Quality of nursing records in a hospital: auditCalidad de los registros de enfermería en un hospital: auditoriaQualidade dos registros de enfermagem em um hospital: auditoriaRegistros de enfermeríaCalidadIncumplimientoIntervenciónControlPrescripción. Registros de enfermagemQualidadeInconformidadeIntervençãoControlePrescrição.Nursing recordsQualityNon-complianceInterventionControlPrescription. Objective to evaluate, through auditing, the effectiveness of nursing records in a public hospital in Goiás. Method This is a descriptive and analytical study, carried out on medical records of patients hospitalized in a public hospital in Goiás. hospital stay longer than five days in neonatal, pediatric and maternal intensive care units. For data analysis, we used the comparison of means of continuous variables through the Mann-Whitney test. Results it was verified that the inadequate filling of the medical records compromised the quality criteria, before and after the educational action. However, the means inherent to complete, incomplete and unfilled information in relation to medical records were significantly repaired after the educational action (p<0.05). The categories, identification data (PP=81.16%) and the execution of medical orders (PP=89.13%) had higher adequacy rates regarding complete records. The nursing prescription compromised the quality, regarding the incorrect filling of the records in (PP=6.76%). Conclusion nursing records do not meet the quality criteria, even after the educational action, considering that the effectiveness of the records underwent minor adjustments. It is recommended that educational actions be instituted in the hospital's health policies.Objetivo evaluar, mediante auditoría, la efectividad de los registros de enfermería en un hospital público de Goiás. Método Se trata de un estudio descriptivo y analítico, realizado sobre historias clínicas de pacientes hospitalizados en un hospital público de Goiás. En unidades de cuidados intensivos neonatales, pediátricos y maternos. Para el análisis de los datos se utilizó la comparación de medias de variables continuas mediante la prueba de Mann-Whitney. Resultados Se verificó que el llenado inadecuado de las historias clínicas comprometió los criterios de calidad, antes y después de la acción educativa. Sin embargo, los medios inherentes a la información completa, incompleta y sin completar en relación a la historia clínica se repararon significativamente después de la acción educativa (p <0.05). Las categorías, datos de identificación (PP = 81,16%) y ejecución de órdenes médicas (PP = 89,13%) tuvieron mayores tasas de adecuación con respecto a registros completos. La prescripción de enfermería comprometió la calidad, con respecto al llenado incorrecto de los registros en (PP = 6,76%). Conclusión Los registros de enfermería no cumplen con los criterios de calidad, incluso después de la acción educativa, considerando que la efectividad de los registros sufrió pequeños ajustes. Se recomienda que se instituyan acciones educativas en las políticas de salud del hospital.Objetivo avaliar por meio da auditoria a eficácia dos registros de enfermagem em um hospital público de Goiás. Método trata-se de um estudo descritivo e analítico, realizado em prontuários de pacientes hospitalizados em um hospital público de Goiás. Analisaram-se prontuários de pacientes com tempo de internação superior a cinco dias, em unidades de terapia intensiva neonatal, pediátrica e materna. Para análise dos dados, utilizou-se a comparação das médias das variáveis contínuas através do teste de Mann-Whitney. Resultado verificou-se que o preenchimento inadequado dos prontuários comprometeu os critérios da qualidade, antes e após a ação educativa. No entanto as médias inerentes às informações completas, incompletas e não preenchidas em relação aos prontuários foram significativamente reparadas após a ação educativa (p<0,05). As categorias, dados de identificação (PP=81,16%) e a execução das ordens médicas (PP=89,13%) apresentaram maiores índices de adequação quanto aos registros completos. A prescrição de enfermagem comprometeu a qualidade, quanto ao preenchimento incorreto dos registros em (PP=6,76%). Conclusão os registros de enfermagem não correspondem aos critérios da qualidade, mesmo após a ação educativa, tendo em vista que a eficácia dos registros passou por ajustes pequenos. Recomenda-se que ações educativas sejam instituídas nas políticas de saúde do hospital.Research, Society and Development2021-08-11info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfhttps://rsdjournal.org/index.php/rsd/article/view/1868410.33448/rsd-v10i10.18684Research, Society and Development; Vol. 10 No. 10; e229101018684Research, Society and Development; Vol. 10 Núm. 10; e229101018684Research, Society and Development; v. 10 n. 10; e2291010186842525-3409reponame:Research, Society and Developmentinstname:Universidade Federal de Itajubá (UNIFEI)instacron:UNIFEIporhttps://rsdjournal.org/index.php/rsd/article/view/18684/16846Copyright (c) 2021 Ludimila Cristina Souza Silva ; Marinésia Aparecida do Prado; Lilian Carla Carneiro; Aroldo Vieira de Moraes Filho; Tatieny Aparecida Martins da Costa; Danielle Perdigão Oliveira e Ribeiro; Ana Lúcia Queiroz Bezerra; Maria Alves Barbosahttps://creativecommons.org/licenses/by/4.0info:eu-repo/semantics/openAccessSilva , Ludimila Cristina Souza Prado, Marinésia Aparecida do Carneiro, Lilian Carla Moraes Filho, Aroldo Vieira de Costa, Tatieny Aparecida Martins da Ribeiro, Danielle Perdigão Oliveira e Bezerra, Ana Lúcia Queiroz Barbosa, Maria Alves 2021-10-02T21:49:16Zoai:ojs.pkp.sfu.ca:article/18684Revistahttps://rsdjournal.org/index.php/rsd/indexPUBhttps://rsdjournal.org/index.php/rsd/oairsd.articles@gmail.com2525-34092525-3409opendoar:2024-01-17T09:38:45.403411Research, Society and Development - Universidade Federal de Itajubá (UNIFEI)false |
| dc.title.none.fl_str_mv |
Quality of nursing records in a hospital: audit Calidad de los registros de enfermería en un hospital: auditoria Qualidade dos registros de enfermagem em um hospital: auditoria |
| title |
Quality of nursing records in a hospital: audit |
| spellingShingle |
Quality of nursing records in a hospital: audit Silva , Ludimila Cristina Souza Registros de enfermería Calidad Incumplimiento Intervención Control Prescripción. Registros de enfermagem Qualidade Inconformidade Intervenção Controle Prescrição. Nursing records Quality Non-compliance Intervention Control Prescription. |
| title_short |
Quality of nursing records in a hospital: audit |
| title_full |
Quality of nursing records in a hospital: audit |
| title_fullStr |
Quality of nursing records in a hospital: audit |
| title_full_unstemmed |
Quality of nursing records in a hospital: audit |
| title_sort |
Quality of nursing records in a hospital: audit |
| author |
Silva , Ludimila Cristina Souza |
| author_facet |
Silva , Ludimila Cristina Souza Prado, Marinésia Aparecida do Carneiro, Lilian Carla Moraes Filho, Aroldo Vieira de Costa, Tatieny Aparecida Martins da Ribeiro, Danielle Perdigão Oliveira e Bezerra, Ana Lúcia Queiroz Barbosa, Maria Alves |
| author_role |
author |
| author2 |
Prado, Marinésia Aparecida do Carneiro, Lilian Carla Moraes Filho, Aroldo Vieira de Costa, Tatieny Aparecida Martins da Ribeiro, Danielle Perdigão Oliveira e Bezerra, Ana Lúcia Queiroz Barbosa, Maria Alves |
| author2_role |
author author author author author author author |
| dc.contributor.author.fl_str_mv |
Silva , Ludimila Cristina Souza Prado, Marinésia Aparecida do Carneiro, Lilian Carla Moraes Filho, Aroldo Vieira de Costa, Tatieny Aparecida Martins da Ribeiro, Danielle Perdigão Oliveira e Bezerra, Ana Lúcia Queiroz Barbosa, Maria Alves |
| dc.subject.por.fl_str_mv |
Registros de enfermería Calidad Incumplimiento Intervención Control Prescripción. Registros de enfermagem Qualidade Inconformidade Intervenção Controle Prescrição. Nursing records Quality Non-compliance Intervention Control Prescription. |
| topic |
Registros de enfermería Calidad Incumplimiento Intervención Control Prescripción. Registros de enfermagem Qualidade Inconformidade Intervenção Controle Prescrição. Nursing records Quality Non-compliance Intervention Control Prescription. |
| description |
Objective to evaluate, through auditing, the effectiveness of nursing records in a public hospital in Goiás. Method This is a descriptive and analytical study, carried out on medical records of patients hospitalized in a public hospital in Goiás. hospital stay longer than five days in neonatal, pediatric and maternal intensive care units. For data analysis, we used the comparison of means of continuous variables through the Mann-Whitney test. Results it was verified that the inadequate filling of the medical records compromised the quality criteria, before and after the educational action. However, the means inherent to complete, incomplete and unfilled information in relation to medical records were significantly repaired after the educational action (p<0.05). The categories, identification data (PP=81.16%) and the execution of medical orders (PP=89.13%) had higher adequacy rates regarding complete records. The nursing prescription compromised the quality, regarding the incorrect filling of the records in (PP=6.76%). Conclusion nursing records do not meet the quality criteria, even after the educational action, considering that the effectiveness of the records underwent minor adjustments. It is recommended that educational actions be instituted in the hospital's health policies. |
| publishDate |
2021 |
| dc.date.none.fl_str_mv |
2021-08-11 |
| dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion |
| format |
article |
| status_str |
publishedVersion |
| dc.identifier.uri.fl_str_mv |
https://rsdjournal.org/index.php/rsd/article/view/18684 10.33448/rsd-v10i10.18684 |
| url |
https://rsdjournal.org/index.php/rsd/article/view/18684 |
| identifier_str_mv |
10.33448/rsd-v10i10.18684 |
| dc.language.iso.fl_str_mv |
por |
| language |
por |
| dc.relation.none.fl_str_mv |
https://rsdjournal.org/index.php/rsd/article/view/18684/16846 |
| dc.rights.driver.fl_str_mv |
https://creativecommons.org/licenses/by/4.0 info:eu-repo/semantics/openAccess |
| rights_invalid_str_mv |
https://creativecommons.org/licenses/by/4.0 |
| eu_rights_str_mv |
openAccess |
| dc.format.none.fl_str_mv |
application/pdf |
| dc.publisher.none.fl_str_mv |
Research, Society and Development |
| publisher.none.fl_str_mv |
Research, Society and Development |
| dc.source.none.fl_str_mv |
Research, Society and Development; Vol. 10 No. 10; e229101018684 Research, Society and Development; Vol. 10 Núm. 10; e229101018684 Research, Society and Development; v. 10 n. 10; e229101018684 2525-3409 reponame:Research, Society and Development instname:Universidade Federal de Itajubá (UNIFEI) instacron:UNIFEI |
| instname_str |
Universidade Federal de Itajubá (UNIFEI) |
| instacron_str |
UNIFEI |
| institution |
UNIFEI |
| reponame_str |
Research, Society and Development |
| collection |
Research, Society and Development |
| repository.name.fl_str_mv |
Research, Society and Development - Universidade Federal de Itajubá (UNIFEI) |
| repository.mail.fl_str_mv |
rsd.articles@gmail.com |
| _version_ |
1797052808088780800 |