Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes

Detalhes bibliográficos
Autor(a) principal: Sulzbach, Suéli Regina
Data de Publicação: 2022
Outros Autores: Argenta, Carla, Adamy, Edlamar Kátia, Meschial, William Campo, Zanatta, Elisangela Argenta, Abido, Suzanne Cristina
Tipo de documento: Artigo
Idioma: por
eng
Título da fonte: Revista de Enfermagem da Universidade Federal de Santa Maria
Texto Completo: http://periodicos.ufsm.br/reufsm/article/view/68189
Resumo: Objective: to evaluate the quality of nursing process records in medical records of an adult intensive care unit. Method: cross-sectional study, with application of the Quality of Diagnoses, Interventions and Outcomes in 145 medical records of patients who were hospitalized from November 2018 to June 2019. Results: in relation to the domain called Nursing Diagnoses as a process, only 27% of the records were complete. In the nursing diagnostics as a product domain, the results were satisfactory with 97% of the complete documentation. Satisfaction remained in nursing interventions, in which completeness was obtained in 94% of the medical records. As for the Results, more than half of the records presented inconsistencies. Conclusion: the records of the Nursing Process have been executed in the intensive care unit in a partially satisfactory way, and, from this study, it is possible to develop strategies to improve the quality of records.
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spelling Evaluation of nursing records through Quality of Diagnoses, Interventions and OutcomesEvaluación de los registros de enfermería a través del Quality of Diagnoses, Interventions and OutcomesAvaliação dos registros de enfermagem por meio do Quality of Diagnoses, Interventions and OutcomesRegistros de enfermagemProcesso de enfermagemDiagnósticos de enfermagemEnfermagemServiço Hospitalar de EducaçãoProcesso de EnfermagemRegistros de EnfermeríaProceso de EnfermeríaDiagnósticos de EnfermeríaEnfermeríaServicio de Educación HospitalariaNursing RecordsNursing ProcessNursing DiagnosesNursingHospital Education ServiceObjective: to evaluate the quality of nursing process records in medical records of an adult intensive care unit. Method: cross-sectional study, with application of the Quality of Diagnoses, Interventions and Outcomes in 145 medical records of patients who were hospitalized from November 2018 to June 2019. Results: in relation to the domain called Nursing Diagnoses as a process, only 27% of the records were complete. In the nursing diagnostics as a product domain, the results were satisfactory with 97% of the complete documentation. Satisfaction remained in nursing interventions, in which completeness was obtained in 94% of the medical records. As for the Results, more than half of the records presented inconsistencies. Conclusion: the records of the Nursing Process have been executed in the intensive care unit in a partially satisfactory way, and, from this study, it is possible to develop strategies to improve the quality of records.Objetivo: evaluar la calidad de los registros del proceso de enfermería en los registros médicos de una unidad de cuidados intensivos de adultos. Método: estudio transversal, con aplicación del Quality of Diagnoses, Interventions and Outcomes en 145 historias clínicas de pacientes hospitalizados desde noviembre de 2018 hasta junio de 2019. Resultados: en relación al dominio denominado Diagnósticos de Enfermería como proceso, sólo el 27% de los registros fueron completos. En el dominio del diagnóstico de enfermería como producto, los resultados fueron satisfactorios con el 97% de la documentación completa. La satisfacción se mantuvo en las intervenciones de enfermería, en las que se obtuvo completitud en el 94% de las historias clínicas. En cuanto a los resultados, más de la mitad de los registros presentaron inconsistencias. Conclusión: los registros del Proceso de Enfermería se han ejecutado en la unidad de cuidados intensivos de manera parcialmente satisfactoria, y, a partir de este estudio, es posible desarrollar estrategias para mejorar la calidad de los registros.Objetivo: avaliar a qualidade dos registros do Processo de Enfermagem em prontuários de uma unidade de terapia intensiva adulto. Método: estudo transversal, com aplicação do Quality of Diagnoses, Interventions and Outcomes em 145 prontuários de pacientes que estiveram internados no período de novembro de 2018 a junho de 2019. Resultados: em relação ao domínio denominado Diagnósticos de Enfermagem como processo, apenas 27% dos registros apresentaram-se completos. No domínio Diagnósticos de Enfermagem como produto, os resultados foram satisfatórios com 97% da documentação completa. A satisfatoriedade se manteve nas Intervenções de Enfermagem, em que a completude foi obtida em 94% dos prontuários. Quanto aos Resultados, mais da metade dos registros apresentaram inconsistências. Conclusão: os registros do Processo de Enfermagem vêm sendo executados na unidade de terapia intensiva de forma parcialmente satisfatória, e, a partir deste estudo, é possível desenvolver estratégias para melhoria da qualidade dos registros.Universidade Federal de Santa Maria2022-07-11info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfapplication/pdftext/htmltext/htmlhttp://periodicos.ufsm.br/reufsm/article/view/6818910.5902/2179769268189Revista de Enfermagem da UFSM; v. 12 (2022); e262179-7692reponame:Revista de Enfermagem da Universidade Federal de Santa Mariainstname:Universidade Federal de Santa Maria (UFSM)instacron:UFSMporenghttp://periodicos.ufsm.br/reufsm/article/view/68189/47793http://periodicos.ufsm.br/reufsm/article/view/68189/47794http://periodicos.ufsm.br/reufsm/article/view/68189/47795http://periodicos.ufsm.br/reufsm/article/view/68189/47796Copyright (c) 2022 Revista de Enfermagem da UFSMhttp://creativecommons.org/licenses/by-nc-sa/4.0info:eu-repo/semantics/openAccessSulzbach, Suéli ReginaArgenta, CarlaAdamy, Edlamar KátiaMeschial, William CampoZanatta, Elisangela ArgentaAbido, Suzanne Cristina2022-12-29T17:45:21Zoai:ojs.pkp.sfu.ca:article/68189Revistahttps://periodicos.ufsm.br/reufsmPUBhttp://cascavel.ufsm.br/revistas/ojs-2.2.2/index.php/reufsm/oaicentraldeperiodicos@ufsm.br||reufsm@gmail.com2179-76922179-7692opendoar:2022-12-29T17:45:21Revista de Enfermagem da Universidade Federal de Santa Maria - Universidade Federal de Santa Maria (UFSM)false
dc.title.none.fl_str_mv Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
Evaluación de los registros de enfermería a través del Quality of Diagnoses, Interventions and Outcomes
Avaliação dos registros de enfermagem por meio do Quality of Diagnoses, Interventions and Outcomes
title Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
spellingShingle Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
Sulzbach, Suéli Regina
Registros de enfermagem
Processo de enfermagem
Diagnósticos de enfermagem
Enfermagem
Serviço Hospitalar de Educação
Processo de Enfermagem
Registros de Enfermería
Proceso de Enfermería
Diagnósticos de Enfermería
Enfermería
Servicio de Educación Hospitalaria
Nursing Records
Nursing Process
Nursing Diagnoses
Nursing
Hospital Education Service
title_short Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
title_full Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
title_fullStr Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
title_full_unstemmed Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
title_sort Evaluation of nursing records through Quality of Diagnoses, Interventions and Outcomes
author Sulzbach, Suéli Regina
author_facet Sulzbach, Suéli Regina
Argenta, Carla
Adamy, Edlamar Kátia
Meschial, William Campo
Zanatta, Elisangela Argenta
Abido, Suzanne Cristina
author_role author
author2 Argenta, Carla
Adamy, Edlamar Kátia
Meschial, William Campo
Zanatta, Elisangela Argenta
Abido, Suzanne Cristina
author2_role author
author
author
author
author
dc.contributor.author.fl_str_mv Sulzbach, Suéli Regina
Argenta, Carla
Adamy, Edlamar Kátia
Meschial, William Campo
Zanatta, Elisangela Argenta
Abido, Suzanne Cristina
dc.subject.por.fl_str_mv Registros de enfermagem
Processo de enfermagem
Diagnósticos de enfermagem
Enfermagem
Serviço Hospitalar de Educação
Processo de Enfermagem
Registros de Enfermería
Proceso de Enfermería
Diagnósticos de Enfermería
Enfermería
Servicio de Educación Hospitalaria
Nursing Records
Nursing Process
Nursing Diagnoses
Nursing
Hospital Education Service
topic Registros de enfermagem
Processo de enfermagem
Diagnósticos de enfermagem
Enfermagem
Serviço Hospitalar de Educação
Processo de Enfermagem
Registros de Enfermería
Proceso de Enfermería
Diagnósticos de Enfermería
Enfermería
Servicio de Educación Hospitalaria
Nursing Records
Nursing Process
Nursing Diagnoses
Nursing
Hospital Education Service
description Objective: to evaluate the quality of nursing process records in medical records of an adult intensive care unit. Method: cross-sectional study, with application of the Quality of Diagnoses, Interventions and Outcomes in 145 medical records of patients who were hospitalized from November 2018 to June 2019. Results: in relation to the domain called Nursing Diagnoses as a process, only 27% of the records were complete. In the nursing diagnostics as a product domain, the results were satisfactory with 97% of the complete documentation. Satisfaction remained in nursing interventions, in which completeness was obtained in 94% of the medical records. As for the Results, more than half of the records presented inconsistencies. Conclusion: the records of the Nursing Process have been executed in the intensive care unit in a partially satisfactory way, and, from this study, it is possible to develop strategies to improve the quality of records.
publishDate 2022
dc.date.none.fl_str_mv 2022-07-11
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 http://periodicos.ufsm.br/reufsm/article/view/68189
10.5902/2179769268189
url http://periodicos.ufsm.br/reufsm/article/view/68189
identifier_str_mv 10.5902/2179769268189
dc.language.iso.fl_str_mv por
eng
language por
eng
dc.relation.none.fl_str_mv http://periodicos.ufsm.br/reufsm/article/view/68189/47793
http://periodicos.ufsm.br/reufsm/article/view/68189/47794
http://periodicos.ufsm.br/reufsm/article/view/68189/47795
http://periodicos.ufsm.br/reufsm/article/view/68189/47796
dc.rights.driver.fl_str_mv Copyright (c) 2022 Revista de Enfermagem da UFSM
http://creativecommons.org/licenses/by-nc-sa/4.0
info:eu-repo/semantics/openAccess
rights_invalid_str_mv Copyright (c) 2022 Revista de Enfermagem da UFSM
http://creativecommons.org/licenses/by-nc-sa/4.0
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv application/pdf
application/pdf
text/html
text/html
dc.publisher.none.fl_str_mv Universidade Federal de Santa Maria
publisher.none.fl_str_mv Universidade Federal de Santa Maria
dc.source.none.fl_str_mv Revista de Enfermagem da UFSM; v. 12 (2022); e26
2179-7692
reponame:Revista de Enfermagem da Universidade Federal de Santa Maria
instname:Universidade Federal de Santa Maria (UFSM)
instacron:UFSM
instname_str Universidade Federal de Santa Maria (UFSM)
instacron_str UFSM
institution UFSM
reponame_str Revista de Enfermagem da Universidade Federal de Santa Maria
collection Revista de Enfermagem da Universidade Federal de Santa Maria
repository.name.fl_str_mv Revista de Enfermagem da Universidade Federal de Santa Maria - Universidade Federal de Santa Maria (UFSM)
repository.mail.fl_str_mv centraldeperiodicos@ufsm.br||reufsm@gmail.com
_version_ 1799944045199360000

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