Analysis of the production process and understanding of the medical record in the hospital environment
| Autor(a) principal: | |
|---|---|
| Data de Publicação: | 2021 |
| Outros Autores: | , , , , , , , , , , , , |
| Tipo de documento: | Artigo |
| Idioma: | por |
| Título da fonte: | Research, Society and Development |
| Texto Completo: | https://rsdjournal.org/index.php/rsd/article/view/13349 |
Resumo: | This study aimed to analyze, through the literature, the scientific evidence that involves the processes of production and understanding of the nursing record in the hospital environment. It is an integrative literature review, in which the following question was asked: “What is the scientific evidence about the process of production and understanding of the nursing record in the hospital environment?”. A PICo strategy was set up, in which, through descriptors and keywords, the databases of the National Library of Medicine were consulted; VHL (Virtual Health Library), and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Thirteen studies were included in this review. Most studies dealt with the key components for the elaboration of the medical record, emphasizing its purpose, quality and use in the hospital environment; the main conformities and non-conformities; the implications under rules and regulations; and the difficulties encountered by professionals regarding the sector and the assistance phase. Regarding the flaws in the nursing records, studies cited that most professionals are unaware of the institution's requirements, the current legislation and the code of ethics. It is concluded that nursing professionals must adopt permanent training measures for correct adherence to medical records, seek resolution on fragmented service, and learn from their own mistakes, so that there are no complications in the actions to be performed with regard to the patient hospitalized. |
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Analysis of the production process and understanding of the medical record in the hospital environmentAnálisis del proceso de producción y comparación del prontuário de enfermagem no ambiente hospitalarAnálise do processo de produção e compreensão do prontuário de enfermagem no ambiente hospitalarNursing professionalsNursing recordsHospitals.Profesionales de enfermeríaRegistros de enfermeríaHospitales. Profissionais de enfermagemRegistros de enfermagemHospitais.This study aimed to analyze, through the literature, the scientific evidence that involves the processes of production and understanding of the nursing record in the hospital environment. It is an integrative literature review, in which the following question was asked: “What is the scientific evidence about the process of production and understanding of the nursing record in the hospital environment?”. A PICo strategy was set up, in which, through descriptors and keywords, the databases of the National Library of Medicine were consulted; VHL (Virtual Health Library), and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Thirteen studies were included in this review. Most studies dealt with the key components for the elaboration of the medical record, emphasizing its purpose, quality and use in the hospital environment; the main conformities and non-conformities; the implications under rules and regulations; and the difficulties encountered by professionals regarding the sector and the assistance phase. Regarding the flaws in the nursing records, studies cited that most professionals are unaware of the institution's requirements, the current legislation and the code of ethics. It is concluded that nursing professionals must adopt permanent training measures for correct adherence to medical records, seek resolution on fragmented service, and learn from their own mistakes, so that there are no complications in the actions to be performed with regard to the patient hospitalized.Este estudio tuvo como objetivo analizar, a través de la literatura, la evidencia científica que involucra los procesos de producción y comprensión del registro de enfermería en el ámbito hospitalario. Se trata de una revisión integradora de la literatura, en la que se planteó la siguiente pregunta: “¿Cuál es la evidencia científica sobre el proceso de producción y comprensión del registro de enfermería en el ámbito hospitalario?”. Se estableció una estrategia PICo, en la cual, a través de descriptores y palabras clave, se consultaron las bases de datos de la Biblioteca Nacional de Medicina; BVS (Biblioteca Virtual en Salud) y CINAHL (Índice Acumulativo de Literatura de Enfermería y Afines en Salud). Se incluyeron trece estudios en esta revisión. La mayoría de los estudios abordaron los componentes clave para la elaboración de la historia clínica, destacando su finalidad, calidad y uso en el ámbito hospitalario; las principales conformidades y no conformidades; las implicaciones bajo las reglas y regulaciones; y las dificultades encontradas por los profesionales en el sector y la fase asistencial. En cuanto a las fallas en los registros de enfermería, estudios citan que la mayoría de los profesionales desconocen los requisitos de la institución, la legislación vigente y el código ético. Se concluye que los profesionales de enfermería deben adoptar medidas de formación permanente para la correcta adherencia a la historia clínica, buscar la resolución del servicio fragmentado y aprender de sus propios errores, para que no existan complicaciones en las acciones a realizar con respecto al paciente hospitalizado.O presente estudo objetivou analisar por meio da literatura, as evidências científicas que envolvem os processos de produção e compreensão do prontuário de enfermagem no ambiente hospitalar. Trata-se de uma revisão integrativa de literatura, em que formulou-se a seguinte questão: “Quais as evidências cientificas sobre o processo de produção e compreensão do prontuário de enfermagem no ambiente hospitalar?”. Montou-se uma estratégia PICo, na qual por meio de descritores e palavras-chave foram consultadas as bases de dados da National Library of Medicine; BVS (Biblioteca Virtual da Saúde), e CINAHL (Cumulative Index to Nursing and Allied Health Literature). Foram incluídos treze estudos nesta revisão. A maioria dos estudos versou sobre os componentes chaves para a elaboração do prontuário, enfatizando sua finalidade, qualidade e a utilização no ambiente hospitalar; as principais conformidades e não conformidades; as implicações segundo as normas e regulamentos; e as dificuldades encontradas pelos profissionais referentes ao setor e a fase da assistência. Com relação às falhas nos registros de enfermagem, estudos citaram que a maioria dos profissionais desconhece os requisitos da instituição, as legislações vigentes e o código de ética. Conclui-se que os profissionais de enfermagem devem adotar medidas de capacitação permanente para a adesão correta do prontuário, buscar resolutividades sobre o serviço fragmentado, e aprender com seus próprios erros, para que não haja complicações nas ações a serem realizadas no que tange ao paciente hospitalizado.Research, Society and Development2021-03-14info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfhttps://rsdjournal.org/index.php/rsd/article/view/1334910.33448/rsd-v10i3.13349Research, Society and Development; Vol. 10 No. 3; e23910313349Research, Society and Development; Vol. 10 Núm. 3; e23910313349Research, Society and Development; v. 10 n. 3; e239103133492525-3409reponame:Research, Society and Developmentinstname:Universidade Federal de Itajubá (UNIFEI)instacron:UNIFEIporhttps://rsdjournal.org/index.php/rsd/article/view/13349/11941Copyright (c) 2021 Thalia Jeovana da Silva Pereira; Wenderson Costa da Silva; Hálmisson D’Árley Santos Siqueira; Rogério Cruz Mendes; Marta Valeria Soares Chaves; Brunna Matos Sousa; Railson Muniz de Sousa; Karen Laís Azevêdo Oliveira Sousa; Lisianne Natália Santos Silva; Tatila Shinaira Soares Chaves; Linccon Fricks Hernandes; Maria Gabrielle Sobral da Silva; Melissa Torres Soares Rabêlo ; Layse Siqueira Costa Mirandahttps://creativecommons.org/licenses/by/4.0info:eu-repo/semantics/openAccess Pereira, Thalia Jeovana da SilvaSilva, Wenderson Costa da Siqueira, Hálmisson D’Árley Santos Mendes, Rogério Cruz Chaves, Marta Valeria Soares Sousa, Brunna Matos Sousa, Railson Muniz de Sousa, Karen Laís Azevêdo Oliveira Silva, Lisianne Natália Santos Chaves, Tatila Shinaira Soares Hernandes, Linccon FricksSilva, Maria Gabrielle Sobral da Rabêlo , Melissa Torres Soares Miranda, Layse Siqueira Costa 2021-03-28T12:03:35Zoai:ojs.pkp.sfu.ca:article/13349Revistahttps://rsdjournal.org/index.php/rsd/indexPUBhttps://rsdjournal.org/index.php/rsd/oairsd.articles@gmail.com2525-34092525-3409opendoar:2024-01-17T09:34:42.763695Research, Society and Development - Universidade Federal de Itajubá (UNIFEI)false |
| dc.title.none.fl_str_mv |
Analysis of the production process and understanding of the medical record in the hospital environment Análisis del proceso de producción y comparación del prontuário de enfermagem no ambiente hospitalar Análise do processo de produção e compreensão do prontuário de enfermagem no ambiente hospitalar |
| title |
Analysis of the production process and understanding of the medical record in the hospital environment |
| spellingShingle |
Analysis of the production process and understanding of the medical record in the hospital environment Pereira, Thalia Jeovana da Silva Nursing professionals Nursing records Hospitals. Profesionales de enfermería Registros de enfermería Hospitales. Profissionais de enfermagem Registros de enfermagem Hospitais. |
| title_short |
Analysis of the production process and understanding of the medical record in the hospital environment |
| title_full |
Analysis of the production process and understanding of the medical record in the hospital environment |
| title_fullStr |
Analysis of the production process and understanding of the medical record in the hospital environment |
| title_full_unstemmed |
Analysis of the production process and understanding of the medical record in the hospital environment |
| title_sort |
Analysis of the production process and understanding of the medical record in the hospital environment |
| author |
Pereira, Thalia Jeovana da Silva |
| author_facet |
Pereira, Thalia Jeovana da Silva Silva, Wenderson Costa da Siqueira, Hálmisson D’Árley Santos Mendes, Rogério Cruz Chaves, Marta Valeria Soares Sousa, Brunna Matos Sousa, Railson Muniz de Sousa, Karen Laís Azevêdo Oliveira Silva, Lisianne Natália Santos Chaves, Tatila Shinaira Soares Hernandes, Linccon Fricks Silva, Maria Gabrielle Sobral da Rabêlo , Melissa Torres Soares Miranda, Layse Siqueira Costa |
| author_role |
author |
| author2 |
Silva, Wenderson Costa da Siqueira, Hálmisson D’Árley Santos Mendes, Rogério Cruz Chaves, Marta Valeria Soares Sousa, Brunna Matos Sousa, Railson Muniz de Sousa, Karen Laís Azevêdo Oliveira Silva, Lisianne Natália Santos Chaves, Tatila Shinaira Soares Hernandes, Linccon Fricks Silva, Maria Gabrielle Sobral da Rabêlo , Melissa Torres Soares Miranda, Layse Siqueira Costa |
| author2_role |
author author author author author author author author author author author author author |
| dc.contributor.author.fl_str_mv |
Pereira, Thalia Jeovana da Silva Silva, Wenderson Costa da Siqueira, Hálmisson D’Árley Santos Mendes, Rogério Cruz Chaves, Marta Valeria Soares Sousa, Brunna Matos Sousa, Railson Muniz de Sousa, Karen Laís Azevêdo Oliveira Silva, Lisianne Natália Santos Chaves, Tatila Shinaira Soares Hernandes, Linccon Fricks Silva, Maria Gabrielle Sobral da Rabêlo , Melissa Torres Soares Miranda, Layse Siqueira Costa |
| dc.subject.por.fl_str_mv |
Nursing professionals Nursing records Hospitals. Profesionales de enfermería Registros de enfermería Hospitales. Profissionais de enfermagem Registros de enfermagem Hospitais. |
| topic |
Nursing professionals Nursing records Hospitals. Profesionales de enfermería Registros de enfermería Hospitales. Profissionais de enfermagem Registros de enfermagem Hospitais. |
| description |
This study aimed to analyze, through the literature, the scientific evidence that involves the processes of production and understanding of the nursing record in the hospital environment. It is an integrative literature review, in which the following question was asked: “What is the scientific evidence about the process of production and understanding of the nursing record in the hospital environment?”. A PICo strategy was set up, in which, through descriptors and keywords, the databases of the National Library of Medicine were consulted; VHL (Virtual Health Library), and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Thirteen studies were included in this review. Most studies dealt with the key components for the elaboration of the medical record, emphasizing its purpose, quality and use in the hospital environment; the main conformities and non-conformities; the implications under rules and regulations; and the difficulties encountered by professionals regarding the sector and the assistance phase. Regarding the flaws in the nursing records, studies cited that most professionals are unaware of the institution's requirements, the current legislation and the code of ethics. It is concluded that nursing professionals must adopt permanent training measures for correct adherence to medical records, seek resolution on fragmented service, and learn from their own mistakes, so that there are no complications in the actions to be performed with regard to the patient hospitalized. |
| publishDate |
2021 |
| dc.date.none.fl_str_mv |
2021-03-14 |
| dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion |
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article |
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publishedVersion |
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https://rsdjournal.org/index.php/rsd/article/view/13349 10.33448/rsd-v10i3.13349 |
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https://rsdjournal.org/index.php/rsd/article/view/13349 |
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10.33448/rsd-v10i3.13349 |
| dc.language.iso.fl_str_mv |
por |
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por |
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https://rsdjournal.org/index.php/rsd/article/view/13349/11941 |
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https://creativecommons.org/licenses/by/4.0 info:eu-repo/semantics/openAccess |
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https://creativecommons.org/licenses/by/4.0 |
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openAccess |
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application/pdf |
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Research, Society and Development |
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Research, Society and Development |
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Research, Society and Development; Vol. 10 No. 3; e23910313349 Research, Society and Development; Vol. 10 Núm. 3; e23910313349 Research, Society and Development; v. 10 n. 3; e23910313349 2525-3409 reponame:Research, Society and Development instname:Universidade Federal de Itajubá (UNIFEI) instacron:UNIFEI |
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Research, Society and Development |
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Research, Society and Development |
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Research, Society and Development - Universidade Federal de Itajubá (UNIFEI) |
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rsd.articles@gmail.com |
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