Retrospective analysis of nursing records at a specialized unit

Authors

  • Kattia Ochoa-Vigo Universidade de São Paulo; Escola de Enfermagem de Ribeirão Preto
  • Ana Emilia Pace Universidade de São Paulo; Escola de Enfermagem de Ribeirão Preto
  • Claudia Benedita dos Santos Universidade de São Paulo; Escola de Enfermagem de Ribeirão Preto

DOI:

https://doi.org/10.1590/S0104-11692003000200007

Keywords:

nursing records, nursing assessment, nursing team

Abstract

This is a retrospective longitudinal study conducted in a Specialized Unit in the interior of Brazil. It aimed at verifying differences in nursing records with regard to how to document the care provided to patients in three periods related to the implementation of the Nursing process. Data were collected from 20% of the records of patients aged over 15 years who were randomly selected according to proportional distribution. Such data were fully transcribed in an instrument constructed for this purpose and classified according to the proposals of the referential. The Binomial Test was used for analysis with a significance level of 0.05%. The results showed a tendency to improvement of the records as to writing intellection and complete description of the signs/symptoms in the second period. It was concluded that there was a difference between the initial and the pre-implementation periods, which expresses the need to review the way the Nursing Process must be developed as a responsibility of the whole nursing team.

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Published

2003-03-01

Issue

Vol. 11 No. 2 (2003)

Section

Original Articles

License

RLAE’s authorship concept is based on the substantial contribution by each of the individuals listed as authors, mainly in terms of conceiving and planning the research project, collecting or analyzing and interpreting data, writing and critical review. Indication of authors’ names under the article title is limited to six. If more, authors are listed on the online submission form under Acknowledgements. The possibility of including more than six authors will only be examined on multicenter studies, considering the explanations presented by the authors.
Including names of authors whose contribution does not fit into the above criteria cannot be justified. Those names can be included in the Acknowledgements section.
 Authors are fully responsible for the concepts disseminated in their manuscripts, which do not necessarily reflect the editors’ and editorial board’s opinion.

 

How to Cite

Retrospective analysis of nursing records at a specialized unit. (2003). Revista Latino-Americana De Enfermagem, 11(2), 184-191. https://doi.org/10.1590/S0104-11692003000200007