The quality of nursing notes in an intensive care unit of a university hospital

Authors

  • Fabiane Gorni Borsato Universidade Estadual de Londrina
  • Mariana Ângela Rossaneis Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto
  • Maria do Carmo Fernandez Lourenço Haddad Universidade Estadual de Londrina
  • Marli Terezinha Oliveira Vannuchi Universidade Estadual de Londrina
  • Dagmar Willamowius Vituri Universidade Estadual de Londrina, Hospital Unversitário Regional do Norte do Paraná

DOI:

https://doi.org/10.5216/ree.v14i3.13513

Keywords:

Nursing, Nursing Care, Quality Management, Nursing Records

Abstract

Nursing notes are sources of information that allow for multiprofessional communication. The objective of this study was to evaluate the quality of the nursing notes in the intensive care unit of a university hospital. A descriptive-quantitative study was performed utilizing secondary data collection from quality assessment records of nursing notes from 2009. The report results were compared according to the following criteria: complete, incomplete, blank and incorrect, considering, respectively, a satisfactory score of more than 80%, below 15%, less than 5%, and 0%. Satisfactory scores were found for cases involving at least one note per shift and including pre and post-operative care/exams. There was a reduction in the scores for signs and symptoms, complications and response to the nursing care. Regarding textual esthetics, results were unsatisfactory for author identification and item checklists. Results revealed several inadequacies, proving the need for educational measures, and the improvement of nurses’ skills and service.

Descriptors: Nursing; Nursing Care; Quality Management; Nursing Records.

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Author Biographies

Fabiane Gorni Borsato, Universidade Estadual de Londrina

Enfermeira. Discente do Programa de Mestrado Acadêmico do Departamento de Enfermagem da Universidade Estadual de Londrina (UEL). Enfermeira do serviço de controle de qualidade em enfermagem do Hospital Dr. Anísio Figueiredo. Londrina, PR, Brasil. E-mail: fabigorni@hotmail.com.

Mariana Ângela Rossaneis, Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto

Enfermeira. Discente do Programa de Enfermagem Fundamental (PPGEF) da Escola de Enfermagem de Ribeirão Preto (EERP) da Universidade de São Paulo (USP), nível Mestrado. Londrina, PR, Brasil. E-mail: marianaangela08@hotmail.com.

Maria do Carmo Fernandez Lourenço Haddad, Universidade Estadual de Londrina

Enfermeira, Doutora em Enfermagem. Professor Associado do Departamento de Enfermagem/UEL. Londrina, PR, Brasil. E-mail: haddad@sercomtel.com.br.

Marli Terezinha Oliveira Vannuchi, Universidade Estadual de Londrina

Enfermeira, Doutora em Saúde Pública. Professor Associado do Departamento de Enfermagem/UEL. Londrina, PR, Brasil. E-mail: vannuchi@sercomtel.com.br.

Dagmar Willamowius Vituri, Universidade Estadual de Londrina, Hospital Unversitário Regional do Norte do Paraná

Enfermeira, Mestre em Enfermagem. Discente do PPGEF/EERP/USP, nível Doutorado. Enfermeira do Hospital Universitário Regional do Norte do Paraná/UEL. Londrina, PR, Brasil. E-mail: dagmar@uel.br.

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Published

2012-09-30

Issue

Vol. 14 No. 3 (2012)

Section

Original Article