Evaluation of the registrations of the nursing consultations in gynecology

Abstract

The gynecological nursing consultation involves a complex process of information, requiring the interview and physical examination completes, in order to subsidize an assistance of quality. The purpose of this study was to evaluate the records of the gynecological nursing consultation at the Center of Natural Childbirth of Federal University of Ceara. A retrospective documentary study with predominantly quantitative approach, held in November 2006, with a sample composed by 200 records. The instrument used was a check list, prepared in accordance with the requirements that the Ministry of Health recommended to be present in a consultation in gynaecology. Of the 42 items surveyed, only 3 were recorded in 100% of records: name, address and age, and only 1 item was not recorded in 100% of cases: bimanual touch. While a portion of the data (7 items) has been recorded in less than 60% of records, the number of items recorded in 100% of them was even lower (3 items). These results show the necessity to monitor the academics nursing faculty in the health service, and the importance of registration data in a comprehensive manner so as to correct and remedy existing weaknesses and promote the completion of 100% of the records of the nursing consultations.

Keywords: Records of nursing; Women's health; Education in nursing; Gynecology.