Nursing records/notes: communication instrument for the quality of nursing care?

Abstract

This is a documental type study that analyzed 124 nursing records/notes (51 of registered nurses and 73 of practical nurses). After accomplishing the ethical demands regarding this study, the data was collected from the patients record of the Adult Intensive Care Unit* and that later were moved out to the Medical or Surgical Unit. It was analyzed the nursing records made in the first three days of the patient internment in this two units, being used a form with questions regarding the structure and the aesthetics of them. The results pointed that 80,4% of the registered nurses didn't put the date close to the nursing care records and 72,5% omitted the hours. Regarding to the practical nurses, 53,5% didn't mention the date and 90,4% noted down just the period corresponding to the shift, but not the hours. It was also observed that a total of 57 deletions made by the two categories, the prevalent way of correction were to write over the wrong word(s). The presences of general/evasive terms and abbreviations that difficult the understanding of the nursing care records was frequent. The data indicate that the records are not written in a systematic way, and that can commit its functionality and usefulness as communication instrument for the quality of the nursing care.