Analysis of nursing notes on patients' medical records in a Teaching Hospital

Detalhes bibliográficos
Autor(a) principal: Barral, Luana Nayara Maia
Data de Publicação: 2012
Outros Autores: Ramos, Laís Helena, Vieira, Maria Aparecida, Dias, Orlene Veloso, Souza e Souza, Luís Paulo
Tipo de documento: Artigo
Idioma: por
Título da fonte: Reme (Online)
Texto Completo: https://periodicos.ufmg.br/index.php/reme/article/view/50308
Resumo: This study aims at assessing nursing notes on patients' admission at the clinic of a Teaching Hospital in Montes Claros, State of Minas Gerais. It is a quantitative, descriptive and documentary study carried out from January to December 2008. Data collection was conducted in 253 medical records through probability sampling guided by theoretical references and the current legislation. Theanalyzed notes were in accordance with the standards of the Regional Nursing Council of Minas Gerais. The records conveyed date (96.8%), time (90.5%), in a legible handwriting (87.4%), a full professional identification (76.3%). There was absence of blank spaces (94.1%), comments or erasures (98%), and information unrelated to the client (0.4%). Misspellings were adequately corrected (86.2%) as well as nonstandard abbreviations (5.1%). There were gaps in the nursing notes and/or physical examination records that could jeopardize the medical record functioning as a communication tool. The present study is expected to provide new strategies on education, monitoring and the records systematized assessment to improve care.
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spelling Analysis of nursing notes on patients' medical records in a Teaching HospitalAnálisis de las notas de enfermería en registros médicos de pacientes en un hospital universitarioAnálise dos registros de enfermagem em prontuários de pacientes em um Hospital de EnsinoRegistros médicosnotas de enfermeríapersonal de enfermeríaRegistros de EnfermagemProntuáriosEquipe de EnfermagemMedical RecordsNursing NotesNursing StaffThis study aims at assessing nursing notes on patients' admission at the clinic of a Teaching Hospital in Montes Claros, State of Minas Gerais. It is a quantitative, descriptive and documentary study carried out from January to December 2008. Data collection was conducted in 253 medical records through probability sampling guided by theoretical references and the current legislation. Theanalyzed notes were in accordance with the standards of the Regional Nursing Council of Minas Gerais. The records conveyed date (96.8%), time (90.5%), in a legible handwriting (87.4%), a full professional identification (76.3%). There was absence of blank spaces (94.1%), comments or erasures (98%), and information unrelated to the client (0.4%). Misspellings were adequately corrected (86.2%) as well as nonstandard abbreviations (5.1%). There were gaps in the nursing notes and/or physical examination records that could jeopardize the medical record functioning as a communication tool. The present study is expected to provide new strategies on education, monitoring and the records systematized assessment to improve care.Este estudio tiene como objetivo la evaluación de las notas de enfermería en el ingreso de los pacientes en la clínica médica de un hospital universitario de Montes Claros, Estado de Minas Gerais. Se trata de un estudio cuantitativo, descriptivo y documental realizado entre enero y diciembre de 2008. La recogida de datos fue realizada en 253 registros médicos por muestre o probabilístico guiado por referencias teóricas y de la legislación actual. Los resultados indican que las notas se encontraban en conformidad con las normas del Consejo Regional de Enfermería de Minas Gerais: 96,8% tenían fecha; 90,5% hora; 87,4% letra legible; 76,3% identificación profesional completa; 94,1% ausencia de espacios en blanco; 98% ausencia de comentarios y rasuras; 0,4% informaciones no relacionadas al cliente; 86,2% correcciones adecuadas en cuanto a errores ortográficos; 5,1% abreviaciones no estandarizadas. Hay deficiencias en las notas de enfermería y/o registros de exámenes físicos que podrían comprometer la función del expediente médico como herramienta de comunicación. Se espera que este estudio proporcione nuevas estrategias en materia de educación, seguimiento y evaluación sistemática de los registros para mejorar la atención.O objetivo com esta pesquisa foi avaliar os registros efetuados pela equipe de enfermagem referentes à admissão de pacientes internados na clínica médica de um Hospital de Ensino. Trata-se de estudo quantitativo, descritivo e documental, realizado na clínica médica de um Hospital de ensino, em Montes Claros-Mg, no período de janeiro a dezembro de 2008. A coleta foi realizada em 253 prontuários pela amostragem probabilística, tendo como instrumento roteiro construído com referenciais teóricos e legislação vigente. Os registros encontravam-se em conformidade com normas do Conselho Regional de Enfermagem de Minas Gerais: possuíam data (96,8%); hora (90,5%); letra legível (87,4%); identificação profissional completa (76,3%); ausência de espaço em branco (94,1%); ausência de comentário e rasuras (98%); informações não relacionadas ao cliente (0,4%); correções adequadas quanto a erros ortográficos (86,2%) e abreviaturas não padronizadas (5,1%). Foram observadas inadequações nos históricos de enfermagem/exame físicos, comprometendo a funcionalidade do registro como instrumento de comunicação. Espera-se, com este estudo, propiciar novas estratégias relativas à educação, monitoramento e avaliação sistematizada dos registros para melhoria da assistência.Universidade Federal de Minas Gerais2012-06-01info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersiontext/plainapplication/pdfhttps://periodicos.ufmg.br/index.php/reme/article/view/50308REME-Revista Mineira de Enfermagem; Vol. 16 No. 2 (2012)REME-Revista Mineira de Enfermagem; Vol. 16 Núm. 2 (2012)REME-Revista Mineira de Enfermagem; v. 16 n. 2 (2012)2316-93891415-2762reponame:Reme (Online)instname:Universidade Federal de Minas Gerais (UFMG)instacron:UFMGporhttps://periodicos.ufmg.br/index.php/reme/article/view/50308/41793https://periodicos.ufmg.br/index.php/reme/article/view/50308/41794Copyright (c) 2012 Reme: Revista Mineira de Enfermageminfo:eu-repo/semantics/openAccessBarral, Luana Nayara MaiaRamos, Laís HelenaVieira, Maria AparecidaDias, Orlene VelosoSouza e Souza, Luís Paulo2024-01-24T14:29:18Zoai:periodicos.ufmg.br:article/50308Revistaremeufmg@gmail.comPUBhttps://periodicos.ufmg.br/index.php/reme/oairemeufmg@gmail.com2316-93891415-2762opendoar:2024-01-24T14:29:18Reme (Online) - Universidade Federal de Minas Gerais (UFMG)false
dc.title.none.fl_str_mv Analysis of nursing notes on patients' medical records in a Teaching Hospital
Análisis de las notas de enfermería en registros médicos de pacientes en un hospital universitario
Análise dos registros de enfermagem em prontuários de pacientes em um Hospital de Ensino
title Analysis of nursing notes on patients' medical records in a Teaching Hospital
spellingShingle Analysis of nursing notes on patients' medical records in a Teaching Hospital
Barral, Luana Nayara Maia
Registros médicos
notas de enfermería
personal de enfermería
Registros de Enfermagem
Prontuários
Equipe de Enfermagem
Medical Records
Nursing Notes
Nursing Staff
title_short Analysis of nursing notes on patients' medical records in a Teaching Hospital
title_full Analysis of nursing notes on patients' medical records in a Teaching Hospital
title_fullStr Analysis of nursing notes on patients' medical records in a Teaching Hospital
title_full_unstemmed Analysis of nursing notes on patients' medical records in a Teaching Hospital
title_sort Analysis of nursing notes on patients' medical records in a Teaching Hospital
author Barral, Luana Nayara Maia
author_facet Barral, Luana Nayara Maia
Ramos, Laís Helena
Vieira, Maria Aparecida
Dias, Orlene Veloso
Souza e Souza, Luís Paulo
author_role author
author2 Ramos, Laís Helena
Vieira, Maria Aparecida
Dias, Orlene Veloso
Souza e Souza, Luís Paulo
author2_role author
author
author
author
dc.contributor.author.fl_str_mv Barral, Luana Nayara Maia
Ramos, Laís Helena
Vieira, Maria Aparecida
Dias, Orlene Veloso
Souza e Souza, Luís Paulo
dc.subject.por.fl_str_mv Registros médicos
notas de enfermería
personal de enfermería
Registros de Enfermagem
Prontuários
Equipe de Enfermagem
Medical Records
Nursing Notes
Nursing Staff
topic Registros médicos
notas de enfermería
personal de enfermería
Registros de Enfermagem
Prontuários
Equipe de Enfermagem
Medical Records
Nursing Notes
Nursing Staff
description This study aims at assessing nursing notes on patients' admission at the clinic of a Teaching Hospital in Montes Claros, State of Minas Gerais. It is a quantitative, descriptive and documentary study carried out from January to December 2008. Data collection was conducted in 253 medical records through probability sampling guided by theoretical references and the current legislation. Theanalyzed notes were in accordance with the standards of the Regional Nursing Council of Minas Gerais. The records conveyed date (96.8%), time (90.5%), in a legible handwriting (87.4%), a full professional identification (76.3%). There was absence of blank spaces (94.1%), comments or erasures (98%), and information unrelated to the client (0.4%). Misspellings were adequately corrected (86.2%) as well as nonstandard abbreviations (5.1%). There were gaps in the nursing notes and/or physical examination records that could jeopardize the medical record functioning as a communication tool. The present study is expected to provide new strategies on education, monitoring and the records systematized assessment to improve care.
publishDate 2012
dc.date.none.fl_str_mv 2012-06-01
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://periodicos.ufmg.br/index.php/reme/article/view/50308
url https://periodicos.ufmg.br/index.php/reme/article/view/50308
dc.language.iso.fl_str_mv por
language por
dc.relation.none.fl_str_mv https://periodicos.ufmg.br/index.php/reme/article/view/50308/41793
https://periodicos.ufmg.br/index.php/reme/article/view/50308/41794
dc.rights.driver.fl_str_mv Copyright (c) 2012 Reme: Revista Mineira de Enfermagem
info:eu-repo/semantics/openAccess
rights_invalid_str_mv Copyright (c) 2012 Reme: Revista Mineira de Enfermagem
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv text/plain
application/pdf
dc.publisher.none.fl_str_mv Universidade Federal de Minas Gerais
publisher.none.fl_str_mv Universidade Federal de Minas Gerais
dc.source.none.fl_str_mv REME-Revista Mineira de Enfermagem; Vol. 16 No. 2 (2012)
REME-Revista Mineira de Enfermagem; Vol. 16 Núm. 2 (2012)
REME-Revista Mineira de Enfermagem; v. 16 n. 2 (2012)
2316-9389
1415-2762
reponame:Reme (Online)
instname:Universidade Federal de Minas Gerais (UFMG)
instacron:UFMG
instname_str Universidade Federal de Minas Gerais (UFMG)
instacron_str UFMG
institution UFMG
reponame_str Reme (Online)
collection Reme (Online)
repository.name.fl_str_mv Reme (Online) - Universidade Federal de Minas Gerais (UFMG)
repository.mail.fl_str_mv remeufmg@gmail.com
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