Analysis of the nurse’s notes at an intensive therapy unit

• Autor(a) principal: Fontes, Maria Cristina Ferreira
• Data de Publicação: 2006
• Outros Autores: Mendes, Isabel Amélia Costa, Hayashida, Miyeko, Dalri, Maria Celia Barcellos
• Tipo de documento: Artigo
• Idioma: eng
• Título da fonte: Rev Rene (Online)
• Texto Completo: http://periodicos.ufc.br/rene/article/view/5440
• topic: Nursing records; Patient admission; Intensive Care Units.

This is a retrospective study of the nurse’s notes taken when patients are admitted to the Intensive Therapy Unit of a teaching hospital in the state of Paraná. As secondary database, we used the files of patients hospitalized in the second semester of 2002. Among the 241 collected files, 187 (77.6%) contained the printed version of the nurse’s notes. Most notes were identified by the nurse’s rubrics (50.3%) or name (38.0%). From the qualitative analysis of the 187 nurse’s notes, we extracted 515 contents, recorded with objective writing (56.6%), readable and clear handwriting (56.6%), correct abbreviations (67.0%), free from errors (95.2%) and shortenings (50.7%). Although most analyzed contents were classified as adequate, we observed flaws in some of the examined characteristics. Such features suggest the need for reflection and further investigation.