Avaliação das anotações de enfermagem em prontuários de um hospital universitário
Arquivos
Data
2003
Autores
Labbadia, Lilian Lestingi
Orientadores
Adami, Nilce Piva
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Este 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)
The objectives of this study were to identify the quantitative and qualitative aspects of nursing notes in the records of patients hospitalized in a university hospital; to verify the nursing notes in the patient’s records by comparing records of the admission training unit with the other hospitalization units; to evaluate these data comparing them with the guiding principle of the level 1 pattern of the Brazilian Hospital Accreditation Guide (BHAG) designed for nursing. This was a retrospective and descriptive research with a quantitative approach. The sample consisted of 130 records of patients discharged from hospital (discharges and deaths) in the month of June 2002 in a university hospital of the city of São Paulo. After approval of the research project by the Ethics Committee in Research of this institution, data collect was performed using a program which fulfilled the criteria to evaluate quantitative and qualitative aspects of the nursing notes. In the analyzed records it was observed that the activities related to performance of the medical prescription as a medicamentous therapy as well as the control of vital signs and other controls were completely registered in most of the evaluated records (96.2%, 72.6% and 67.7, respectively). Notes on procedures requiring observation and details of the actions preformed by the nursing staff and which are independent of the medical prescription reached values below 40%. The notes, in spite of adequate regarding its shape, revealed to be incomplete in relation to the analyzed contents. Identification of who performed the activity, which is one of the BHAG observation items and a legal requirement of the COFEN, was completely present in values below 30%, not making possible to formally identify who performed the activity. The nursing staff’s performance at the training unit was greater than the other units in relation to discharge records– discharge (p-value = 0.001). When comparing data with the guiding principle of the level 1 BHAG, items related to control of patients and legibility of the notes were the only ones presenting values greater than 90%. The main conclusions were: the nursing activities performed in this institution aimed at the achievement of medical prescriptions; notes were not thoroughly described and were fragmented not making possible the identification of the minimum aspects of the nursing conducts aiming at security and continuity of the hospitalized patient’s assistance consequently involving ethic and legal aspects of the documentation.
The objectives of this study were to identify the quantitative and qualitative aspects of nursing notes in the records of patients hospitalized in a university hospital; to verify the nursing notes in the patient’s records by comparing records of the admission training unit with the other hospitalization units; to evaluate these data comparing them with the guiding principle of the level 1 pattern of the Brazilian Hospital Accreditation Guide (BHAG) designed for nursing. This was a retrospective and descriptive research with a quantitative approach. The sample consisted of 130 records of patients discharged from hospital (discharges and deaths) in the month of June 2002 in a university hospital of the city of São Paulo. After approval of the research project by the Ethics Committee in Research of this institution, data collect was performed using a program which fulfilled the criteria to evaluate quantitative and qualitative aspects of the nursing notes. In the analyzed records it was observed that the activities related to performance of the medical prescription as a medicamentous therapy as well as the control of vital signs and other controls were completely registered in most of the evaluated records (96.2%, 72.6% and 67.7, respectively). Notes on procedures requiring observation and details of the actions preformed by the nursing staff and which are independent of the medical prescription reached values below 40%. The notes, in spite of adequate regarding its shape, revealed to be incomplete in relation to the analyzed contents. Identification of who performed the activity, which is one of the BHAG observation items and a legal requirement of the COFEN, was completely present in values below 30%, not making possible to formally identify who performed the activity. The nursing staff’s performance at the training unit was greater than the other units in relation to discharge records– discharge (p-value = 0.001). When comparing data with the guiding principle of the level 1 BHAG, items related to control of patients and legibility of the notes were the only ones presenting values greater than 90%. The main conclusions were: the nursing activities performed in this institution aimed at the achievement of medical prescriptions; notes were not thoroughly described and were fragmented not making possible the identification of the minimum aspects of the nursing conducts aiming at security and continuity of the hospitalized patient’s assistance consequently involving ethic and legal aspects of the documentation.
Descrição
Citação
LABBADIA, Lilian Lestingi. Avaliação das anotações de enfermagem em prontuários de um hospital universitário. São Paulo, 2003. Dissertação (Mestrado em Enfermagem) - Departamento de Enfermagem, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2003.