A qualidade dos registros de enfermagem do centro obstétrico da Maternidade Escola da Universidade Federal do Rio de Janeiro

Abstract

Nursing records made in patients' charts are considered legal documents and must be legible, complete, authentic and organized. The purpose of study was to identify nonconformities related to nursing records in the maternity clinic. 54 records of nurses from the outpatient clinic of that institution, collected between the months of September/2015 to April/2016. The results showed that 88.9% of the records were complete, 92.6% contained stamp, 100% were legible and only 7.4% were found to have typographical errors. orthography. Abbreviations not standardized by the institution were found in 88.9%, blank spaces between one annotation and another in 85.1% and strikethroughs in 55.6%. even though some positive results regarding the findings, some inadequacies were found and need to be reviewed to ensure the quality of nursing records and the legitimacy of their work process.