[Analysis of nursing records in a surgical ward of a public teaching hospital].
This article presents a systematic descriptive and retrospective study on nursing notes on patients admitted to the surgical ward of a teaching hospital in Londrina, Paraná, Brazil, which aimed at their systematic analisys. Results show that the largest number of notes was made during the morning shift, and most of them were made by nurse auxiliaries. As to basic needs, psychobiological records were the most frequent, whereas there no psychospiritual records were found. It was concluded that nursing notes must be improved, and take into account integral care of patients.
de Carvalho
Cesar Junior Aparecido
CJ
Universidade do Norte do Paraná e Mestre pela Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo na área de concentração Enfermagem Fundamental. carvalho541@hotmail.com
Nogueira
Maria Suely
MS
D000339:Affect; D001938:Brazil; D013505:Digestive System Surgical Procedures; D006301:Health Services Needs and Demand; D006779:Hospitals, Public / Q000706:statistics & numerical data*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009723:Nurse-Patient Relations; D009728:Nursing Assistants; D009732:Nursing Care / Q000592:standards; D009737:Nursing Records / Q000592:standards / Q000706:statistics & numerical data*; D009949:Orientation; D010361:Patients / Q000523:psychology; D012189:Retrospective Studies; D029181:Spirituality; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data*; D013997:Time Factors; D013520:Urologic Surgical Procedures