Evaluation of the nursing process used at a Brazilian teaching hospital.
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.
de Moraes Lopes
Maria Helena Baena
MH
Nursing Department of the Faculty of Medical Sciences, University of Campinas, Brazil. mhbaenaml@yahoo.com.br
Higa
Rosângela
R
Dos Reis
Maria José
MJ
de Oliveira
Neila Regina
NR
Christóforo
Fátima Filomena Mafra
FF
D001938:Brazil; D006784:Hospitals, Teaching / Q000458:organization & administration*; D009736:Nursing Process