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- ItemAcesso aberto (Open Access)Avaliação das anotações de enfermagem em prontuários de um hospital universitário(Universidade Federal de São Paulo (UNIFESP), 2003) Labbadia, Lilian Lestingi [UNIFESP] ; Adami, Nilce Piva [UNIFESP]; http://lattes.cnpq.br/9462726149672876; http://lattes.cnpq.br/4088009570911927Este estudo teve por objetivos: identificar aspectos quantitativos e qualitativos das anotacoes de enfermagem nos prontuarios de pacientes internados em um hospital universitario; verificar as anotacoes de enfermagem nos prontuarios de pacientes comparando os registros da unidade de treinamento admissional com as de outras unidades de internacao; e avaliar estes dados confrontando-os com o principio orientador do padrao do nivel 1 do Manual Brasileiro de Acreditacao Hospitalar (MBAH) estabelecido para a enfermagem. A pesquisa foi do tipo descritiva e retrospectiva, com abordagem quantitativa. A amostra foi composta por 130 prontuarios de pacientes com saidas (altas e obitos) no mes de junho de 2002 em um hospital universitario da cidade de São Paulo. Apos a aprovacao do projeto de pesquisa pelo Comite de Etica em Pesquisa dessa instituicao, a coleta de dados foi realizada utilizando-se um roteiro que contemplou criterios para avaliacao de aspectos quantitativos e qualitativos das anotacoes de enfermagem. Verificou-se nos prontuarios analisados que as atividades relacionadas a execucao da prescricao medica como terapeutica medicamentosa assim como o controle de sinais vitais e outros controles foram registradas na forma completa na maior parte dos prontuarios avaliados (96,2 por cento, 72,6 por cento e 67,7 por cento, respectivamente). As anotacoes dos procedimentos que exigem observacao e detalhamento das acoes realizadas pela equipe de enfermagem e que independem da prescricao medica alcancaram valores inferiores a 40 por cento. As anotacoes, apesar de adequadas quanto a forma, revelaram-se incompletas em relacao aos conteudos analisados. A identificacao da executora da atividade, um dos itens de observacao do MBAH e exigencia legal do COFEN, estava presente na forma completa em valores inferiores a 30 por cento, impossibilitando a identificacao formal da executora da atividade. O desempenho da equipe de enfermagem da unidade de treinamento foi superior ao das outras unidades apenas em relacao aos registros de saida - alta (p-valor = 0,001). No confronto dos dados com o principio orientador do Nivel 1 do MBAH, verificou-se que os itens relacionados aos controles dos pacientes e a legibilidade das anotacoes foram os unicos que apresentaram valores superiores a 90 por cento. As principais conclusoes foram: as atividades de enfermagem realizadas nesta instituicao estavam voltadas, ainda_ (AU)
- ItemAcesso aberto (Open Access)Avaliação dos registros de enfermeiros em prontuários de pacientes internados em unidade de clínica médica(Escola Paulista de Enfermagem, Universidade Federal de São Paulo (UNIFESP), 2012-01-01) Franco, Maria Teresa Gomes; Akemi, Elizabeth Nishio; D´inocento, Maria [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)OBJECTIVE: To analyze the nursing records (RE) completed by nurses in patients' records of an internal medicine (CM) unit of a public hospital. METHODS: The study sample consisted of 240 (100%) records of patients who were discharged or died, between February and April, 2008. The classification criteria for completion were based on those established by the institution being researched. RESULTS: The records were filled out completely for the majority of the items: nursing history (99.9%); multidisciplinary progress (80.0%) and risk assessment (99.6%). Regarding the consistency of the completion, the highlights were: 88.4% of nursing prescriptions classified as compliant; diagnosis and nursing progress 58.7% and 64.6% as non-conforming, respectively. As to the identification of nursing: 98.3% completed the nursing history, 87.9% were in progress, and 75.4% of the diagnosis and nursing prescription. CONCLUSION: The detected nonconformities confront the importance given by the institution for completion of the records, training and vigilance of the audit committee of nursing.
- ItemAcesso aberto (Open Access)Conjunto de Dados Mínimos em Enfermagem: identificação de categorias e itens para a prática de enfermagem em saúde ocupacional ambulatorial(Associação Brasileira de Enfermagem, 2006-04-01) Silveira, Denise Tolfo [UNIFESP]; Marin, Heimar de Fatima [UNIFESP]; Universidade Federal de São Paulo (UNIFESP); Universidade Federal do Rio Grande do Sul Escola de Enfermagem Departamento de Enfermagem Médico-CirúrgicoThis article describes the categorization of the elements identified from the nursing check-up in ambulatory occupational health. This is a retrospective descriptive study that was conducted in the Nursing Ambulatory Center at Hospital de Clínicas de Porto Alegre. The data sources were the nursing records used in outpatient unit and from the records of the institution's database, collected from August 1998 to August 2003. Of the106 patient records used, 777 records were identified as first-time encounter and nursing return appointments. The initial results of this study suggest that the demographic elements of the patient/client, nursing care elements, service elements, and occupational health elements comprise a nursing essential data set in the area of occupational health.
- ItemAcesso aberto (Open Access)Conjunto Internacional de Dados Essenciais de Enfermagem: comparação com dados na área de Saúde da Mulher(Escola Paulista de Enfermagem, Universidade Federal de São Paulo (UNIFESP), 2010-04-01) Marin, Heimar de Fatima [UNIFESP]; Barbieri, Márcia [UNIFESP]; Barros, Sonia Maria Oliveira de [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)OBJECTIVE: To compare the International Data Set - Essentials of Nursing - with the nursing data set used in data collection forms for the area of Women's Health. METHODS: This is an observational, retrospective, descriptiveand correlational study, developed from forms of data collection of interest of nursing in the health area of motherhood validated. RESULTS: In the first category, from all six present items, four were included. In the second, all can be considered as present, including the gender item, although it was not explicit, was included because of the studied area. The third category was completely covered by the forms. CONCLUSION: The forms used were considered satisfactory, serving for the purposes of documentation and analysis of the nursing work process and making possible to quantify and qualify their contribution to the quality of care provided to women in the sectors studied.
- ItemAcesso aberto (Open Access)Erros de medicação em pediatria: análise da documentação de enfermagem no prontuário do paciente(Associação Brasileira de Enfermagem, 2005-04-01) Melo, Liliane Rodrigues [UNIFESP]; Pedreira, Mavilde da Luz Gonçalves [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Descriptive and correlational study which aimed to verify medication errors through the analyzes of medical charts of children admitted in three pediatric wards of a university hospital. The errors could represent record gaps verified on the care process documentation, that do not compromise the patient safety. In the 68 medical charts 1717 errors were verified, 21.1% of the 8152 drugs doses or solutions ordered during the studied period. More than 13 categories of errors were identified, omission errors (dose or records) were the most frequents (75.7%). The types of errors indicated the need of continuous education and the implementation of management tools that allowed the development of the practice and monitoring results.
- ItemAcesso aberto (Open Access)Mapeamento cruzado: uma alternativa para a análise de dados em enfermagem(Escola Paulista de Enfermagem, Universidade Federal de São Paulo (UNIFESP), 2005-03-01) Lucena, Amália De Fátima; Barros, Alba Lucia Bottura Leite de [UNIFESP]; Universidade Federal do Rio Grande do Sul; Universidade Federal de São Paulo (UNIFESP)The technological evolution of the information field has been steady along the present days thus making the nursing science to pursue its development in the same area. As such, there is the need to develop the classifications for nursing practice, with standard languages which allow for the communication of its body of knowledge and practice. Reality in Brazil shows that there are very few attempts to use those Classifications, either diagnoses, interventions or outcomes, although there are many nursing records with non-standard language. This article aims at introducing and describing the Cross-mapping method, which provides a mapping of nursing records with non-standardized language into standardized classification systems. The article is also a very brief approach to some existing classifications and it encompasses an example of how to use the Cross-mapping method, its processes and rules, as a helping tool for research development in the field, thus playing its role in the nursing body of knowledge.
- ItemAcesso aberto (Open Access)Proposta de um instrumento de avaliação da saúde do idoso institucionalizado baseado no conceito do Conjunto de Dados Essenciais em Enfermagem(Associação Brasileira de Enfermagem, 2009-04-01) Ribeiro, Rita de Cássia [UNIFESP]; Marin, Heimar de Fatima [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)This article aims at presenting a health evaluation tool for the institutionalized aged developed under the concepts of the Nursing Minimum Data Set (NMDS) divided in two sections: identification and health evaluation. It is a methodological research about the development of a data collection tool. The tool is constituted of two sections: Section A contains identification data in the admission, and Section B is the Total Assessment Form, containing data of cognitive, communication, hearing, vision, mood and behavior patterns, and physiological and nutritional conditions. It was concluded that this tool is capable of aggregating the most important data to subside nursing assistance in the care of the institutionalized aged.
- ItemAcesso aberto (Open Access)Qualidade das anotações de enfermagem relacionadas à ressuscitação cardiopulmonar comparadas ao modelo Utstein(Escola Paulista de Enfermagem, Universidade Federal de São Paulo (UNIFESP), 2010-01-01) Fernandes, Ana Paula [UNIFESP]; Vancini, Cássia Regina [UNIFESP]; Cohrs, Frederico Molina [UNIFESP]; Moreira, Rita Simone Lopes [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)OBJECTIVE: To assess the quality of nursing records related to cardiopulmonary resuscitation, comparing them to the validated Utstein protocol, in a university hospital. METHODS: Retrospective, exploratory and descriptive study, with quantitative approach, performed by means of consultation records of patients that suffered cardiorespiratory arrest (CRA) followed by death. The data collection was carried out in the period of May 1st to June 30th, in 2009. RESULTS: Of the 144 medical records surveyed, 74 were dismissed for not having any recorded information on the items to be studied and, 70 constituted the study sample. In these there were no entries on: the immediate cause of CRA (92%); the interventions seeking to recover the cardiorespiratoy arrest (RCA) (71%); on the initial rate of CRA (59%); on the time of events (16%); on drugs used (50%); and, on the professionals involved in RCA (88%). CONCLUSIONS: The notes were scarce and often not realized. The use of the Utstein model favors the annotation sequence of events, avoiding data loss.