title: Evaluation of the nursing process used at a Brazilian teaching hospital.
abstract: OBJECTIVE
  To evaluate how the nursing process has been registered at a Brazilian teaching hospital.
  
  
  METHODS
  Descriptive and retrospective study of 68 medical records.
  
  
  RESULTS
  The data collection of history was more frequent on the admission day. The documentation of physical exam was prioritized. Sometimes there were records of nursing interventions but not of nursing diagnoses.
  
  
  CONCLUSIONS
  It was found some failures in the record of some steps of the nursing process. Although all steps had been used, they were not carried out consistently.
  
  
  CONCLUSIONS
  Some aspects deserve to be considered to improve the use and registration of all steps of the nursing process as to develop specific protocols, redesign the formulary of data record with careful and equal consideration of all steps, and empower all members of the nursing staff to implement the nursing process more effectively.
authors.affiliation: Nursing Department of the Faculty of Medical Sciences, University of Campinas, Brazil. mhbaenaml@yahoo.com.br
authors.forename: Maria Helena Baena
authors.initials: MH
authors.lastname: de Moraes Lopes
authors.forename: Rosângela
authors.initials: R
authors.lastname: Higa
authors.forename: Maria José
authors.initials: MJ
authors.lastname: Dos Reis
authors.forename: Neila Regina
authors.initials: NR
authors.lastname: de Oliveira
authors.forename: Fátima Filomena Mafra
authors.initials: FF
authors.lastname: Christóforo
mesh_terms: D001938:Brazil; D006784:Hospitals, Teaching / Q000458:organization & administration*; D009736:Nursing Process