Audit of medical records: evaluation of tracheal suction registers in intensive care unit

Detalhes bibliográficos
Autor(a) principal: Campos, Juliana Faria
Data de Publicação: 2009
Outros Autores: Souza, Sônia Regina Oliveira Silva e, Saurusaitis, Alessandra Dutkus
Tipo de documento: Artigo
Idioma: por
Título da fonte: Revista Eletrônica de Enfermagem
Texto Completo: https://revistas.ufg.br/fen/article/view/8034
Resumo: It´s a descriptive and exploratory study with quantitative approach that had as objective the evaluation of the register of the procedure of tracheal suctioning in Intensive Care Unit by multiprofessional team using hospitalar auditing. The documentary analysis was used for evaluation of the register of the procedure. It was analised 21 medical records. The sample was composed by 37 registers of the Intensive Care Unit team. The research occurred in the period beteween January and May of 2006 in a public hospital in Rio de Janeiro. For data collection it had been used a check list instrument. To analise the register it was used as parameter a barema. It was observed that 89.6% of nursing staff and 100% of phisiotherapists staff register the procedure incompletely. The lack of register in 10,4% of analyzed nursing and in 100% of medicine medical record was verified. The data indicates that the register of the tracheal suction is defective in the unit in question. Measures of continued education and implementation of a protocol for these procedures are necessary and urgent.Key words: Suction; Intensive Care Units; Nursing auditing; Medical records.
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spelling Audit of medical records: evaluation of tracheal suction registers in intensive care unitAuditoria de la historia clínica del paciente: evaluación de los registros de aspiración traqueal en terapia intensivaAuditoria de prontuário: avaliação dos registros de aspiração traqueal em terapia intensivaSuctionIntensive Care UnitsNursing auditingMedical records.SucciónUnidades de Terapia IntensivaAuditoria de enfermeríaHistoria clínica del paciente.SucçãoUnidades de Terapia IntensivaAuditoria de enfermagemRegistros médicos.It´s a descriptive and exploratory study with quantitative approach that had as objective the evaluation of the register of the procedure of tracheal suctioning in Intensive Care Unit by multiprofessional team using hospitalar auditing. The documentary analysis was used for evaluation of the register of the procedure. It was analised 21 medical records. The sample was composed by 37 registers of the Intensive Care Unit team. The research occurred in the period beteween January and May of 2006 in a public hospital in Rio de Janeiro. For data collection it had been used a check list instrument. To analise the register it was used as parameter a barema. It was observed that 89.6% of nursing staff and 100% of phisiotherapists staff register the procedure incompletely. The lack of register in 10,4% of analyzed nursing and in 100% of medicine medical record was verified. The data indicates that the register of the tracheal suction is defective in the unit in question. Measures of continued education and implementation of a protocol for these procedures are necessary and urgent.Key words: Suction; Intensive Care Units; Nursing auditing; Medical records.Estudio cuyo objetivo era evaluar el registro de la aspiración traqueal en terapia intensiva hecho por el equipo multiprofesional utilizó de los referenciais de la auditoria. Estudio descriptivo, exploratório y cuantitativo. Para la evaluación del registro fué usado la  análisis documental. 21 historias clínica del paciente fueron analizados.  Muestra compuesta por 37 registros del equipo intensivista. La investigación ocurrió entre enero y mayo de 2006, en una institución pública del Río De Janeiro. Datos recogidos usando el instrumento del tipo check list. Los registros habían sido evaluados usándose como parámetro un barema. Fue observado que 89.6% del equipo de la enfermería y 100% del registro de la fisioterapia fueron hecha de manera incompleta. La carencia del registro en 10.4% de las historias clínica del paciente analizadas del equipo de la enfermería y en 100% de la medicina fue verificada. Concluye que el registro de la aspiración traqueal se encuentra defectuoso, siendo esencial que médios de educación continuada y de sensibilización de los profesionales sean tomadas.Palabras clave: Succión; Unidades de Terapia Intensiva; Auditoria de enfermería; Historia clínica del paciente.Estudo descritivo, exploratório com abordagem quantitativa, cujo objetivo foi avaliar o registro da aspiração traqueal em Terapia Intensiva realizado pela equipe multiprofissional utilizando-se dos referenciais da auditoria. Para avaliação dos registros foi utilizada análise documental. Foram analisados 21 prontuários.  Amostra composta por 37 registros da equipe intensivista. A pesquisa deu-se entre janeiro a maio de 2006, em uma instituição pública do Rio de Janeiro. Dados coletados utilizando-se instrumento do tipo check list. Os registros foram avaliados utilizando-se como parâmetro um barema. Observou-se que 89,6% da equipe de enfermagem e 100% da fisioterapia registram de modo incompleto o procedimento. Foi verificada a falta do registro em 10,4% dos prontuários analisados da equipe de enfermagem e em 100% da medicina. Conclui-se que o registro da aspiração traqueal encontra-se falho, sendo imprescindível que medidas de educação continuada e sensibilização dos profissionais sejam adotadas.Palavras chave: Sucção; Unidades de Terapia Intensiva; Auditoria de enfermagem; Registros médicos.Faculdade de Enfermagem da UFG2009-11-02info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfhttps://revistas.ufg.br/fen/article/view/803410.5216/ree.v10i2.8034Revista Eletrônica de Enfermagem; Vol. 10 No. 2 (2008)Revista Eletrônica de Enfermagem; v. 10 n. 2 (2008)1518-1944reponame:Revista Eletrônica de Enfermageminstname:Universidade Federal de Goiás (UFG)instacron:UFGporhttps://revistas.ufg.br/fen/article/view/8034/5813Campos, Juliana FariaSouza, Sônia Regina Oliveira Silva eSaurusaitis, Alessandra Dutkusinfo:eu-repo/semantics/openAccess2020-08-11T00:34:31Zoai:ojs.revistas.ufg.br:article/8034Revistahttps://revistas.ufg.br/fenPUBhttps://revistas.ufg.br/fen/oairee.fen@ufg.br1518-19441518-1944opendoar:2020-08-11T00:34:31Revista Eletrônica de Enfermagem - Universidade Federal de Goiás (UFG)false
dc.title.none.fl_str_mv Audit of medical records: evaluation of tracheal suction registers in intensive care unit
Auditoria de la historia clínica del paciente: evaluación de los registros de aspiración traqueal en terapia intensiva
Auditoria de prontuário: avaliação dos registros de aspiração traqueal em terapia intensiva
title Audit of medical records: evaluation of tracheal suction registers in intensive care unit
spellingShingle Audit of medical records: evaluation of tracheal suction registers in intensive care unit
Campos, Juliana Faria
Suction
Intensive Care Units
Nursing auditing
Medical records.
Succión
Unidades de Terapia Intensiva
Auditoria de enfermería
Historia clínica del paciente.
Sucção
Unidades de Terapia Intensiva
Auditoria de enfermagem
Registros médicos.
title_short Audit of medical records: evaluation of tracheal suction registers in intensive care unit
title_full Audit of medical records: evaluation of tracheal suction registers in intensive care unit
title_fullStr Audit of medical records: evaluation of tracheal suction registers in intensive care unit
title_full_unstemmed Audit of medical records: evaluation of tracheal suction registers in intensive care unit
title_sort Audit of medical records: evaluation of tracheal suction registers in intensive care unit
author Campos, Juliana Faria
author_facet Campos, Juliana Faria
Souza, Sônia Regina Oliveira Silva e
Saurusaitis, Alessandra Dutkus
author_role author
author2 Souza, Sônia Regina Oliveira Silva e
Saurusaitis, Alessandra Dutkus
author2_role author
author
dc.contributor.author.fl_str_mv Campos, Juliana Faria
Souza, Sônia Regina Oliveira Silva e
Saurusaitis, Alessandra Dutkus
dc.subject.por.fl_str_mv Suction
Intensive Care Units
Nursing auditing
Medical records.
Succión
Unidades de Terapia Intensiva
Auditoria de enfermería
Historia clínica del paciente.
Sucção
Unidades de Terapia Intensiva
Auditoria de enfermagem
Registros médicos.
topic Suction
Intensive Care Units
Nursing auditing
Medical records.
Succión
Unidades de Terapia Intensiva
Auditoria de enfermería
Historia clínica del paciente.
Sucção
Unidades de Terapia Intensiva
Auditoria de enfermagem
Registros médicos.
description It´s a descriptive and exploratory study with quantitative approach that had as objective the evaluation of the register of the procedure of tracheal suctioning in Intensive Care Unit by multiprofessional team using hospitalar auditing. The documentary analysis was used for evaluation of the register of the procedure. It was analised 21 medical records. The sample was composed by 37 registers of the Intensive Care Unit team. The research occurred in the period beteween January and May of 2006 in a public hospital in Rio de Janeiro. For data collection it had been used a check list instrument. To analise the register it was used as parameter a barema. It was observed that 89.6% of nursing staff and 100% of phisiotherapists staff register the procedure incompletely. The lack of register in 10,4% of analyzed nursing and in 100% of medicine medical record was verified. The data indicates that the register of the tracheal suction is defective in the unit in question. Measures of continued education and implementation of a protocol for these procedures are necessary and urgent.Key words: Suction; Intensive Care Units; Nursing auditing; Medical records.
publishDate 2009
dc.date.none.fl_str_mv 2009-11-02
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://revistas.ufg.br/fen/article/view/8034
10.5216/ree.v10i2.8034
url https://revistas.ufg.br/fen/article/view/8034
identifier_str_mv 10.5216/ree.v10i2.8034
dc.language.iso.fl_str_mv por
language por
dc.relation.none.fl_str_mv https://revistas.ufg.br/fen/article/view/8034/5813
dc.rights.driver.fl_str_mv info:eu-repo/semantics/openAccess
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv application/pdf
dc.publisher.none.fl_str_mv Faculdade de Enfermagem da UFG
publisher.none.fl_str_mv Faculdade de Enfermagem da UFG
dc.source.none.fl_str_mv Revista Eletrônica de Enfermagem; Vol. 10 No. 2 (2008)
Revista Eletrônica de Enfermagem; v. 10 n. 2 (2008)
1518-1944
reponame:Revista Eletrônica de Enfermagem
instname:Universidade Federal de Goiás (UFG)
instacron:UFG
instname_str Universidade Federal de Goiás (UFG)
instacron_str UFG
institution UFG
reponame_str Revista Eletrônica de Enfermagem
collection Revista Eletrônica de Enfermagem
repository.name.fl_str_mv Revista Eletrônica de Enfermagem - Universidade Federal de Goiás (UFG)
repository.mail.fl_str_mv ree.fen@ufg.br
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