科研之友
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摘要
objective: to analyze the nursing records (re) completed by nurses in patients%26apos; records of an internal medicine (cm) unit of a public hospital. methods: the study sample consisted of 240 (100%) records of patients who were discharged or died, between february and april, 2008. the classification criteria for completion were based on those established by the institution being researched. results: the records were filled out completely for the majority of the items: nursing history (99.9%); multidisciplinary progress (80.0%) and risk assessment (99.6%). regarding the consistency of the completion, the highlights were: 88.4% of nursing prescriptions classified as compliant; diagnosis and nursing progress 58.7% and 64.6% as non-conforming, respectively. as to the identification of nursing: 98.3% completed the nursing history, 87.9% were in progress, and 75.4% of the diagnosis and nursing prescription. conclusion: the detected nonconformities confront the importance given by the institution for completion of the records, training and vigilance of the audit committee of nursing.
