[Nursing reports in a surgical unit at a school hospital].
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.
Venturini
Daniele Aparecida
DA
Departamento de Enfermagem, Universidade Estadual de Maringá, Maringá, PR, Brazil.
Marcon
Sonia Silva
SS
D006784:Hospitals, Teaching; D009731:Nursing Audit; D009737:Nursing Records / Q000592:standards*; D012189:Retrospective Studies; D013503:Surgery Department, Hospital