Análise dos registros do enfermeiro do ambulatório de uma maternidade escola

Abstract

Nursing records held on the charts of patients are considered legal documents and must be legible, complete, authentic and organized. The objective of this study was to identify the non-conformities related to nursing records in a Maternity Clinic School. We analyzed 54 nurse records from the referred institution, collected between months September/2015 and April/2016. The results showed that 88.9% of records were complete, 92.6% contained stamp, 100% were legible and in just 7.4% misspellings found. Non-standard abbreviations by the institution were found at 88.9%, white space between a note and another in 85.1% and erasures in 55.6%. Despite some positive results relating to findings, some inadequacies were found and need to be reviewed to ensure the quality of nursing records and the legitimacy of their working process.