Qualidade dos registros de enfermagem de uma unidade de terapia intensiva neonatal

Abstract

Objective: to evaluate the quality of nursing records in a neonatal intensive care unit. Methods: descriptive study. documentary, retrospective with a quantitative approach that evaluated 360 nursing records in newborns' charts through the application of a form. Results: in relation to the notes of the nurses: 98.3% had a stamp at the end of the record, 100.0% were legible, 12.4% had information divergence, 11.6% had a spelling error, 100.0% had abbreviations, 92.6% blanks, 42.1% erasures. As for the notes of the nursing technicians: 84.5% had a stamp at the end of the record, 87.9% were legible, 23.0% had divergence of information, 63.6% had a spelling error, 99.2% had abbreviations, 73 .6% blanks, 77.4% erasures. Conclusion: the quality of the records was not yet at the desirable level as recommended by the literature. It is believed that the standardization of abbreviations and the construction of institutional protocols can considerably reduce nonconformities in the records at the unit.