title: [Nursing reports in a surgical unit at a school hospital].
abstract: This descriptive study aimed at evaluating the quality of nursing records of surgical patients at a school hospital in the region of Northwestern Paraná State, Brazil. A retrospective audit was undertaken, based on the Systemization of Nursing Assistance as the evaluation method. One hundred thirty-four records were selected. The results showed that only the records regarding post-operation nursing prescriptions, observation of signs and symptoms, and post- operation comments could be considered complete. The annotations regarding the aspect and evolution of the skin lesions, as well as the discharge records were incomplete in 73.9% and 97% of the analyzed records. These results point to the need for education, monitoring and continuous evaluation of nursing records, aiming at their improvement and that of the rendered assistance.
authors.affiliation: Departamento de Enfermagem, Universidade Estadual de Maringá, Maringá, PR, Brazil.
authors.forename: Daniele Aparecida
authors.initials: DA
authors.lastname: Venturini
authors.forename: Sonia Silva
authors.initials: SS
authors.lastname: Marcon
mesh_terms: D006784:Hospitals, Teaching; D009731:Nursing Audit; D009737:Nursing Records / Q000592:standards*; D012189:Retrospective Studies; D013503:Surgery Department, Hospital