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- Title
Annotations of the nursing team: the (dis) appreciation of care for the information provided.
- Authors
de Menezes Caldeira, Mariana; de Souza, Tania Vignuda; de Cássia Melão de Morais, Rita; de Montenegro Medeiros de Moraes, Juliana Rezen; de Cássia Nunes Nascimento, Luciana; Oliveira, Isabel Cristina dos Santos
- Abstract
Objectives: to analyze the annotations of the nursing team in the charts of hospitalized children and to discuss the information described by nursing and its implications for child care. Methods: Qualitative research developed in pediatric ward of General Hospital. Data extracted from the consultation in medical records. Thematic analysis. Results: The annotations were related to data indicating gastrointestinal functioning, motor activity, interpretation of vital signs alterations, use of technological devices, and nursing care as dressings and body hygiene. The space destined to the annotation of the nursing team was restricted to medical prescription sheet that was insignificant and there was no identification of the professional. Conclusion: Nursing professionals only described in the medical prescription sheet information that did not reflect their care and the actual clinical condition of the child regarding the quality of nursing care. On the other hand, there was no movement of the nursing professionals themselves to guarantee a space in the medical record as a member of the health team.
- Subjects
HOSPITAL care of children; CHILDREN'S hospitals; DIGESTION; HEALTH facilities; MEDICAL quality control; MEDICAL referrals; MOTOR ability; NURSING; NURSING records; PEDIATRIC nursing; TEAM nursing; QUALITATIVE research; THEMATIC analysis; DATA quality; MEDICAL records; DATA curation
- Publication
Revista de Pesquisa: Cuidado é Fundamental, 2019, Vol 11, Issue 1, p135
- ISSN
1809-6107
- Publication type
Article
- DOI
10.9789/2175-5361.2019.v11i1.135-141