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- Title
Assessment of Nursing Records of Patients Admitted to the Medical Clinic of a University Hospital from the Northern Region of Minas Gerais State.
- Authors
Figueiredo, Tamara; Nogueira da Silva, Patrick Leonardo; Freitas Guimarães, Larissa; Freitas Guimarães, Camilla; Soares Oliveira, Maricy Kariny; Santos Alves, Elaine Cristina
- Abstract
Objective: The study's purpose has been to assess the nursing records of patients hospitalized in the medical clinic of a university hospital from the Northern region of Minas Gerais State. Methods: It is a descriptive, retrospective, and documental study that has a quantitative approach. The study was carried out with 189 medical records of patients hospitalized in the medical clinic of a university hospital over the period from July to December 2012. Data collection was performed through a form, and data handling was done by simple random probabilistic sampling. Results: It was observed both minimum and maximum hospitalization time of one and 97 days (19.58±13.65), respectively. There has been a prevalence of conformities in the nursing records, as follows: bed, descriptive annotation, date and time, presence of rubric and stamp of the professional, admission, hospital discharge and/or death, check and legible handwriting. Conclusion: The presence of divergences observed in the nursing records compromises the registration functionality as a quality instrument.
- Subjects
GHANA; BRAZIL; ACADEMIC medical centers; HOSPITAL care; HOSPITAL admission &; discharge; RECORDING &; registration; RESEARCH methodology; MEDICAL records; NURSING records; PATIENTS; STATISTICAL sampling; WRITING; QUANTITATIVE research; DISCHARGE planning; DISEASE prevalence; RETROSPECTIVE studies; HOSPITAL mortality
- Publication
Revista de Pesquisa: Cuidado é Fundamental, 2019, Vol 11, Issue 2, p390
- ISSN
1809-6107
- Publication type
Article
- DOI
10.9789/2175-5361.2019.v11i2.390-396