Registros de enfermagem em unidades de terapia intensiva pediátrica: estudo descritivo
Online braz. j. nurs. (Online); 16 (2), 2017
Publication year: 2017
Continuity of care depends on the sharing of information between professionals, which occurs mainly through completion of patient records. Failure to transmit or receive messages may result in risks to patient safety and reflect on the quality of care provided.
Aim:
To verify whether the nursing records in the medical records of patients hospitalized in Unidades de Terapia Intensiva Pediátrica (UTI-P - Units of Pediatric Intensive Care) correspond to the safety needs recommended in the literature.Method:
This is a descriptive and quantitative study, through documentary research in the nursing records of 92 medical records, in three UTI-P.Results:
It was found that in 21.8% of the records there were erasures and in 26.1% there was no complete identification of the care professional.Discussion:
Records should not present erasures, as they make it difficult to plan care. In addition, professionals must include their name and registration number at the end of the information noted.Conclusion:
Records were adequate according to the safety recommendations, although some aspects are still lacking in relation to nursing standards.(AU)
A continuidade do cuidado depende da partilha de informações entre profissionais, que ocorre, sobretudo, por meio de registros. Falhas na transmissão ou recepção das mensagens podem redundar em riscos à segurança dos pacientes e refletir na assistência prestada.
