科研之友
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摘要
objective: to develop a medical record for residents in a long-stay institution for the elderly (lsie) in the state of rio grande do sul, in brazil. methods: this was a research-action, conducted in a lsie in the state of rio grande do sul, in brazil. two researchers and 14 workers participated in the research (a nurse, a doctor, a nutritionist, a social worker, four nursing techniques, two caregivers and four administrators). it was utilized the group meetings with the participants, during the meetings were analyzed and discussed four themes: 1) purpose of the medical record; 2) composition of medical records; contributions of medical records to the lsie; and 4) suggestions regarding medical records. results: to attend the contextual needs, the medical record of residents was developed jointly between researchers and the lsie workers; the proposed medical record was implemented subsequently; it was composed of: personal data of the elderly; medical history; evolution of the multidisciplinary team; prescription and annotation of the nursing technique of care; systematization of nursing assistance; and, assessments (cognitive, affective, functional and social). conclusions: the implemented medical record improved the systematization of care and contributed to improving the care for the elderly.
