QUALITY OF NURSING RECORDS IN INTENSIVE CARE: EVALUATION THROUGH A RETROSPECTIVE AUDIT

Authors

  • Elaine Fátima Padilha Universidade Estadual do Oeste do Paraná (UNIOESTE) - Hospital Universitário do Oeste do Paraná (HUOP)
  • Maria do Carmo Fernandez Lourenço Haddad Universidade Estadual de Londrina (UEL) - Departamento de Enfermagem
  • Laura Misue Matsuda Universidade Estadual de Maringá (UEM) - Departamento de Enfermagem

DOI:

https://doi.org/10.5380/ce.v19i2.32103

Keywords:

Nursing audit, Quality of health care, Evaluation in nursing, Intensive care, Intensive care units.

Abstract

This study aimed to evaluate, through a retrospective audit, the quality of the nursing records made in an Intensive Care Unit in a public teaching hospital. This study analyzed 50 hospital records of clients who had been hospitalized for more than three days in the Department, in the period May – July 2009. Records were considered to be quality if their Percentage of Completion (PoC) ≥ 80%; Incomplete up to 15%; Not Completed with less than 5% and; Incorrect 0%. It was ascertained that no records met all the quality criteria proposed, given that the mean PoC was 46% Complete; 43% Incomplete; 10% Not Completed and 1% Incorrect. It is concluded that the nursing records do not satisfy the quality items, and that investments are therefore necessary in raising awareness, training and constant monitoring of the team, such that adequate records may be made.

Author Biographies

Elaine Fátima Padilha, Universidade Estadual do Oeste do Paraná (UNIOESTE) - Hospital Universitário do Oeste do Paraná (HUOP)

Enfermeira. Mestre pelo Departamento de Enfermagem da Universidade Estadual de Maringá. Enfermeira da Unidade de Terapia Intensiva Adulto do Hospital Universitário do Oeste do Paraná. Cascavel, Paraná, Brasil.

Maria do Carmo Fernandez Lourenço Haddad, Universidade Estadual de Londrina (UEL) - Departamento de Enfermagem

Enfermeira. Doutora em Enfermagem. Docente do Departamento de Enfermagem da Universidade Estadual de Londrina - UEL. Londrina, PR, Brasil.

Laura Misue Matsuda, Universidade Estadual de Maringá (UEM) - Departamento de Enfermagem

Enfermeira. Doutora em Enfermagem. Docente do Departamento de Enfermagem da Universidade Estadual de Maringá - UEM. Maringá, PR, Brasil.

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Published

2014-06-28

How to Cite

Padilha, E. F., Haddad, M. do C. F. L., & Matsuda, L. M. (2014). QUALITY OF NURSING RECORDS IN INTENSIVE CARE: EVALUATION THROUGH A RETROSPECTIVE AUDIT. Cogitare Enfermagem, 19(2). https://doi.org/10.5380/ce.v19i2.32103

Issue

Vol. 19 No. 2 (2014)

Section

ORIGINAL ARTICLE

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