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- Title
Nursing records at a teaching hospital: a quasi-experimental study.
- Authors
Silva Dutra, Herica; Emerich Mendes, Simone; Carneiro, Silvia Miranda; Mazzoni da Costa, Fernanda; da Costa Pereira Barboza, Romanda; Ribeiro, Luiz Cláudio
- Abstract
Aim: to evaluate the records of the nursing staff for compliance with the specific legislation in a teaching hospital considering the institution sector, work shift, the professional category and the number of offenses per registration before and after educational intervention. Method: a quasi-experimental study of pre-test and post-test type with a single group. Result: 826 nursing records were evaluated. The largest number of records was made in the Intensive Care Unit by the practical nurses and the night shift. There was an increase in the number of records made by nursing assistants, in male clinical sectors and female surgery sector. There was a reduction in the occurrence of three or more offenses. The intervention was effective for items such as presence of date, time, signature and professional identification stamp. Discussion: incomplete notes can hamper individual care, undermine the continuity of care and imply risks to patient safety. Conclusion: educational interventions can contribute to improvements in nursing records.
- Subjects
BRAZIL; ACADEMIC medical centers; CHI-squared test; LEGAL compliance; HOSPITAL wards; INTENSIVE care units; RESEARCH methodology; NURSES; NURSES' aides; NURSING practice; NURSING records; NURSING specialties; PERSONNEL management; PRACTICAL nurses; PROBABILITY theory; PROFESSIONS; QUALITY assurance; SHIFT systems; PRE-tests &; post-tests; DATA analysis software; HOSPITAL nursing staff
- Publication
Online Brazilian Journal of Nursing, 2016, Vol 15, Issue 3, p351
- ISSN
1676-4285
- Publication type
Article
- DOI
10.17665/1676-4285.20165470