Evaluation of the quality of nursing records in the emergency department of a teaching hospital

Detalhes bibliográficos
Autor(a) principal: Seignemartin, Beatriz Araújo
Data de Publicação: 2013
Outros Autores: Jesus, Larissa Rodrigues de, Vergílio, Maria Silvia Teixeira Giacomasso, Silva, Eliete Maria
Tipo de documento: Artigo
Idioma: eng
Título da fonte: Rev Rene (Online)
Texto Completo: http://periodicos.ufc.br/rene/article/view/3725
Resumo: Nursing records are all systematized registers made by the nursing team, with legal and ethical implications on research, patient´s safety and communication among health professionals. This quantitative and retrospective cross-sectional study was conducted in a school hospital dedicated to the woman’s care, aiming at evaluating by auditing the quality of the nursing records. The 168 medical records were evaluated according to the standard established by the literature and the legislation of the Professional Council from January to June 2011. The importance of early contact with the patient, incomplete records or lack of information on the assistance rendered, besides nonconformities related to what is expected, were identified. The conclusion is that there is the need of periodic evaluations of the quality of the records and discussions on the results with the nursing team, on its importance regarding legislation, literature and the safety of patients. DOI:https://doi.org/10.15253/2175-6783.2013000600008
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spelling Evaluation of the quality of nursing records in the emergency department of a teaching hospitalNursing RecordsNursing AssessmentNursing Care.Nursing records are all systematized registers made by the nursing team, with legal and ethical implications on research, patient´s safety and communication among health professionals. This quantitative and retrospective cross-sectional study was conducted in a school hospital dedicated to the woman’s care, aiming at evaluating by auditing the quality of the nursing records. The 168 medical records were evaluated according to the standard established by the literature and the legislation of the Professional Council from January to June 2011. The importance of early contact with the patient, incomplete records or lack of information on the assistance rendered, besides nonconformities related to what is expected, were identified. The conclusion is that there is the need of periodic evaluations of the quality of the records and discussions on the results with the nursing team, on its importance regarding legislation, literature and the safety of patients. DOI:https://doi.org/10.15253/2175-6783.2013000600008Universidade Federal do Ceará2013-12-08info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfhttp://periodicos.ufc.br/rene/article/view/3725Rev Rene; Vol. 14 No. 6 (2013)Rev Rene; v. 14 n. 6 (2013)2175-67831517-3852reponame:Rev Rene (Online)instname:Universidade Federal do Ceará (UFC)instacron:UFCenghttp://periodicos.ufc.br/rene/article/view/3725/2945Copyright (c) 2016 Northeast Network Nursing Journalinfo:eu-repo/semantics/openAccessSeignemartin, Beatriz AraújoJesus, Larissa Rodrigues deVergílio, Maria Silvia Teixeira GiacomassoSilva, Eliete Maria2023-02-07T15:39:47Zoai:periodicos.ufc:article/3725Revistahttp://periodicos.ufc.br/renePUBhttp://periodicos.ufc.br/rene/oairene@ufc.br||2175-67831517-3852opendoar:2023-02-07T15:39:47Rev Rene (Online) - Universidade Federal do Ceará (UFC)false
dc.title.none.fl_str_mv Evaluation of the quality of nursing records in the emergency department of a teaching hospital
title Evaluation of the quality of nursing records in the emergency department of a teaching hospital
spellingShingle Evaluation of the quality of nursing records in the emergency department of a teaching hospital
Seignemartin, Beatriz Araújo
Nursing Records
Nursing Assessment
Nursing Care.
title_short Evaluation of the quality of nursing records in the emergency department of a teaching hospital
title_full Evaluation of the quality of nursing records in the emergency department of a teaching hospital
title_fullStr Evaluation of the quality of nursing records in the emergency department of a teaching hospital
title_full_unstemmed Evaluation of the quality of nursing records in the emergency department of a teaching hospital
title_sort Evaluation of the quality of nursing records in the emergency department of a teaching hospital
author Seignemartin, Beatriz Araújo
author_facet Seignemartin, Beatriz Araújo
Jesus, Larissa Rodrigues de
Vergílio, Maria Silvia Teixeira Giacomasso
Silva, Eliete Maria
author_role author
author2 Jesus, Larissa Rodrigues de
Vergílio, Maria Silvia Teixeira Giacomasso
Silva, Eliete Maria
author2_role author
author
author
dc.contributor.author.fl_str_mv Seignemartin, Beatriz Araújo
Jesus, Larissa Rodrigues de
Vergílio, Maria Silvia Teixeira Giacomasso
Silva, Eliete Maria
dc.subject.por.fl_str_mv Nursing Records
Nursing Assessment
Nursing Care.
topic Nursing Records
Nursing Assessment
Nursing Care.
description Nursing records are all systematized registers made by the nursing team, with legal and ethical implications on research, patient´s safety and communication among health professionals. This quantitative and retrospective cross-sectional study was conducted in a school hospital dedicated to the woman’s care, aiming at evaluating by auditing the quality of the nursing records. The 168 medical records were evaluated according to the standard established by the literature and the legislation of the Professional Council from January to June 2011. The importance of early contact with the patient, incomplete records or lack of information on the assistance rendered, besides nonconformities related to what is expected, were identified. The conclusion is that there is the need of periodic evaluations of the quality of the records and discussions on the results with the nursing team, on its importance regarding legislation, literature and the safety of patients. DOI:https://doi.org/10.15253/2175-6783.2013000600008
publishDate 2013
dc.date.none.fl_str_mv 2013-12-08
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 http://periodicos.ufc.br/rene/article/view/3725
url http://periodicos.ufc.br/rene/article/view/3725
dc.language.iso.fl_str_mv eng
language eng
dc.relation.none.fl_str_mv http://periodicos.ufc.br/rene/article/view/3725/2945
dc.rights.driver.fl_str_mv Copyright (c) 2016 Northeast Network Nursing Journal
info:eu-repo/semantics/openAccess
rights_invalid_str_mv Copyright (c) 2016 Northeast Network Nursing Journal
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv application/pdf
dc.publisher.none.fl_str_mv Universidade Federal do Ceará
publisher.none.fl_str_mv Universidade Federal do Ceará
dc.source.none.fl_str_mv Rev Rene; Vol. 14 No. 6 (2013)
Rev Rene; v. 14 n. 6 (2013)
2175-6783
1517-3852
reponame:Rev Rene (Online)
instname:Universidade Federal do Ceará (UFC)
instacron:UFC
instname_str Universidade Federal do Ceará (UFC)
instacron_str UFC
institution UFC
reponame_str Rev Rene (Online)
collection Rev Rene (Online)
repository.name.fl_str_mv Rev Rene (Online) - Universidade Federal do Ceará (UFC)
repository.mail.fl_str_mv rene@ufc.br||
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