title: Nursing process: from literature to practice. What are we actually doing?
abstract: OBJECTIVE
  To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital.
  
  
  METHODS
  Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48 h after admission. The form for data collection was structured according to other reports.
  
  
  RESULTS
  302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records.
  
  
  CONCLUSIONS
  All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.
authors: Instituto de Cardiologia, Fundação Universitária de Cardiologia, Brazil.
authors: Simoni
authors: S
authors: Pokorski
authors: Maria Antonieta
authors: MA
authors: Moraes
authors: Régis
authors: R
authors: Chiarelli
authors: Angelita Paganin
authors: AP
authors: Costanzi
authors: Eneida Rejane
authors: ER
authors: Rabelo
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009729:Nursing; D009736:Nursing Process; D012189:Retrospective Studies