Analysis of records by nursing technicians and nurses in medical records / Análisis de los registros médicos de técnicos de enfermería y de enfermeros / Análise dos registros de técnicos de enfermagem e enfermeiros em prontuários

ABSTRACT Objectives: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. Methods: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records. Results: the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses' records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%. Conclusions: the study showed that nursing professionals perform their records incompletely and often do not document the care provided.

RESUMEN Objetivos: evaluar las no conformidades principales de los registros de enfermería de un hospital público del Nordeste en la ciudad de Natal (Brasil). Métodos: estudio descriptivo, transversal, de enfoque cuantitativo. Se llevó a cabo en enfermerías médicas y quirúrgicas. La muestra constó de 120 registros médicos de pacientes hospitalizados entre octubre y diciembre de 2016. Los datos obtenidos fueron tabulados y analizados por estadística simple en frecuencias absoluta y relativa con el software Microsoft Excel 2013. Se utilizó el Diagrama de Pareto en la evaluación de las no conformidades de los registros. Resultados: entre los principales problemas en los registros de enfermería, se destacó la ausencia de la categoría profesional y del número de la comisión, responsables de un 41,8% de las no conformidades en los registros de técnicos de enfermería, mientras que en las anotaciones de los enfermeros se sobresalió la ausencia de hora y caligrafía ilegible, con un 61,2%. Conclusiones: el estudio demostró que los profesionales de enfermería hacen sus registros de forma incompleta y que muchas veces no documentan el cuidado ofertado.

RESUMO Objetivos: analisar as principais não conformidades dos registros de enfermagem de um hospital público do Nordeste na cidade de Natal. Métodos: estudo descritivo, transversal, abordagem quantitativa. Realizado em enfermarias médicas e cirúrgicas. Amostra composta de 120 prontuários de pacientes internados entre outubro e dezembro de 2016. Os dados obtidos foram tabulados e analisados por estatística simples em frequência absoluta e relativa com o software Microsoft Excel 2013. Para avaliar as não conformidades dos registros, usou-se o Diagrama de Pareto. Resultados: como principais problemas nos registros de enfermagem, destacou-se a ausência da categoria profissional e número do conselho, responsáveis por 41,8% das não conformidades nos registros de técnicos de enfermagem, enquanto nas anotações dos enfermeiros foram a ausência de hora e as letras ilegíveis, com 61,2%. Conclusões: o estudo evidenciou que os profissionais de enfermagem realizam seus registros de forma incompleta e que muitas vezes não documentam o cuidado prestado.

Treinamento formal em documentação fotográfica bidimensional padronizada durante a residência em cirurgia plástica / Formal training in two-dimensional standardized photographic documentation during residency in Plastic Surgery

Introdução: A Cirurgia Plástica exige inúmeras habilidades, conhecimentos e competências, e seu escopo de atuação é amplo e desafiador. Dessa forma, todos os cirurgiões plásticos passam por uma extensa educação/formação, que se inicia durante a residência e continua ao longo da vida. O objetivo deste estudo foi delinear um treinamento formal em documentação fotográfica bidimensional padronizada para complementar o treinamento cirúrgico e científico durante a residência em Cirurgia Plástica. Métodos: Os componentes (as estratégias, os tópicos abordados e os processos de aquisição de habilidades e feedback) do treinamento em documentação fotográfica durante a residência em Cirurgia Plástica foram detalhados. Resultados: As atividades dos residentes, as interações entre os residentes o fotógrafo profissional e os cirurgiões/ preceptores e os tópicos abordados (estúdio fotográfico, câmeras fotográficas, objetivas, princípios fotográficos [exposição, abertura, velocidade, ISO e profundidade de campo], iluminação, preparo e posicionamento dos pacientes e da câmera fotográfica, situações fotográficas, vistas fotográficas, banco fotográfico, formatos de imagens, fotogrametria computadorizada e questões éticas e médico-legais) do programa de treinamento em documentação fotográfica foram delineados. Conclusão: O treinamento em documentação fotográfica complementa o arsenal de habilidades necessários aos residentes de Cirurgia Plástica em formação, com o intuito de melhor prepará-los para as carreiras futuras.

Introduction: Plastic surgery requires diverse skills, knowledge, and competencies, and its scope is broad and challenging. Thus, all plastic surgeons go through extensive education/training, which begins during residency and continues throughout their lives. This study aims to outline a formal training program in 2-dimensional standardized photographic documentation ("photodocumentation") to complement surgical and scientific training during residency in Plastic Surgery. Methods: The components (strategies, topics covered, skills acquisition, and feedback processes) of training in photodocumentation during residency in Plastic Surgery were detailed. Results: Topics in the photodocumentation training program included resident activities, interactions among residents, professional photographers, and surgeons/preceptors, studio settings, cameras, lenses, principles (exposure, aperture, speed, ISO, and depth of field), lighting, preparation and positioning of patients and the camera, photoshoot conditions, photo views, photo database, image formats, computerized photogrammetry, and ethical and medical-legal issues. Conclusion: Training in photodocumentation complements the arsenal of skills needed by residents in Plastic Surgery for continuing education, in order to better prepare them for future careers.

Pedagogical reflective practice of nursing undergraduates: the portfolio as an instrument / Práctica pedagógica reflexiva de licenciados en enfermería: el portafolio como instrumento / Prática pedagógica reflexiva de licenciados de enfermagem: o portfólio como instrumento

Objective Analyzing the narratives related to the pedagogical practice experienced during the Supervised Curricular Internship reported in the portfolios of Nursing undergraduate students, regarding the levels of reflection. Method This is a documentary descriptive exploratory study that examined two of the activities proposed for the portfolio preparation. Results Among the 28 analyzed portfolios, all showed the three levels of reflection (technical, critical and metacritical). Conclusion The students had the opportunity to experience the pedagogical practice and presented reflections at metacritical level, reflecting on their performance, the construction of their teaching identity, and about the importance of reflecting on the practice with the objective of transforming it and transforming themselves. .

Objetivo Analisar as narrativas relacionadas à prática pedagógica vivenciada durante o Estágio Curricular Supervisionado relatadas nos portfólios de licenciandos de Enfermagem, quanto aos níveis de reflexão. Método Trata-se de um estudo documental exploratório-descritivo que analisou duas das atividades propostas para a elaboração do portfólio. Resultados Mostraram que dos 28 portfólios analisados, todos apresentaram os três níveis de reflexão (técnico, crítico e metacrítico). Conclusão Os estudantes tiveram oportunidade de vivenciar a prática pedagógica e apresentaram reflexões em nível metacrítico, refletindo sobre seu desempenho, sobre a construção da sua identidade docente e sobre a importância de refletir sobre a prática, com o objetivo de transformá-la e transformar-se a si mesmo. .

Objetivo Analizar las narrativas relacionadas con la práctica pedagógica vivida durante la Pasantía Curricular Supervisada, relatadas en los portafolios de licenciandos en Enfermería, en cuanto a los niveles de reflexión. Método Se trata de un estudio documental exploratorio-descriptivo que analizó dos de las actividades propuestas para la confección del portafolio. Resultados Mostraron que de los 28 portafolios analizados, todos presentaron los tres niveles de reflexión (técnico, crítico y metacrítico). Conclusión Los estudiantes tuvieron la oportunidad de vivir la práctica pedagógica y presentaron reflexiones a nivel metacrítico, reflexionando acerca de su desempeño, la construcción de su identidad docente y la importancia de reflexionar acerca de la práctica, a fin de convertirla y convertirse a sí mismo. .

Quality and completeness of data documentation in an investigator-initiated trial versus an industry-sponsored trial.

Literature on the quality and completeness of data and documentation in investigator-initiated research studies is scarce. We carried out a study to compare the quality of data and documentation in an investigator-initiated trial (IIT) with those in an industry-sponsored study. We retrospectively studied the archived data pertaining to 42 patients enrolled in two trials, 14 patients in an industry-sponsored study and 28 randomly selected patients from an IIT. Trial-related documents were examined and scored for the completeness of the acquisition of data and for storage as per a pre-formulated checklist. Weighted scores were given for each point on the checklist proportional to its relative importance in the data documentation process. A global score and sub-scores for specific modules were given for each subject. The scores in the two studies were compared using the Mann Whitney U test. The total score for general documents was similar in the IIT (14/14, 100%) and the sponsored study (24/25, 96%). The mean summary global score obtained for study-specific documents (maximum possible score, 32) in the IIT (27.1; 95% CI 26.4-27.8) was also not significantly different from that in the sponsored study (27.9; 95% CI 26.7-29.1; p=0.1291). Thus, investigatorinitiated studies carried out by independent researchers in highvolume academic centres, even without active data monitoring and formal audits, appear to adhere to the high standards laid out in the International Conference on Harmonisation-Good Clinical Practices guidelines, ensuring accuracy and completeness in data documentation and archival.

La auditoría interna y la calidad de la documentación de los ensayos clínicos en Cuba / Internal auditing and the quality of clinical trial documentation in Cuba

Introducción: el Centro Nacional Coordinador de Ensayos Clínicos, garantiza la calidad de la documentación generada en los ensayos clínicos que realiza, con el uso de herramientas como la auditoria. Detecta y/o previene las dificultades, con lo que garantiza la toma de decisiones para eliminar las deficiencias y cumple así con los requisitos establecidos en las normativas nacionales e internacionales. Objetivo: mostrar las principales no conformidades o deficiencias detectadas en auditorías a documentación. Métodos: se analizaron las 29 auditorias realizadas a la documentación de los ensayos clínicos en el período desde el año 2007 hasta el 2011. Se extrajeron las no conformidades de los tres acápites que conforman el informe: revisión del completamiento de todos los capítulos, revisión de la calidad de la documentación que se está archivando y ordenamiento cronológico de la información. Resultados: las principales deficiencias se encontraron en el completamiento documental de los capítulos de la carpeta del ensayo; a su vez se detectaron informaciones desactualizadas o incompletas, así como documentos archivados fuera de lugar. Conclusiones: persisten deficiencias en la documentación que se genera durante el ensayo clínico, por lo que se incumplen de este modo con los requisitos establecidos en las Directrices sobre Buenas Prácticas Clínicas en Cuba emitidas por el Centro para el Control Estatal de los Medicamentos (CECMED) que se relacionan con el protocolo del ensayo(AU)

Introduction: the National Coordinating Center for Clinical Trials guarantees the quality of the documentation issued in clinical trials with the use of tools such as auditing. It detects and/or prevents difficulties, thus assuring decision-making to eliminate deficiencies and to fulfil the requirements of national and international regulations. Objective: to show the major nonconformities or deficiencies identified in audits of clinical trial documentation. Methods: an analysis of 29 audits of clinical trial documentation from 2007 to 2011. The nonconformities of the three sections that comprise the report were considered: review of the completion of each chapter, review of the quality of the filed documentation and chronological data arrangement. Results: the main weaknesses were found in the documentary completion of chapters in the clinical trial folder in addition to outdated or incomplete data and wrongly filed documents. Conclusions: there are still deficiencies in the documentation generated during the clinical trial, and consequently, there is non-compliance of the requirements of the Guidelines on Good Clinical Practices in Cuba issued by the Center for the State Control of Drugs (CECMED) and related to the trial protocol(AU)

Development of a Document Management System for the Standardization of Clinical Laboratory Documents

BACKGROUND: Documentation is very important; a considerable number of documents exist for use in accreditation inspection. However, most laboratories do not effectively manage the processes of documentation, organization, and storage. The purpose of this study was to facilitate the establishment of a strategically effective and sustainably standardized document management system. METHODS: A document code formatting system was modified by comparing the document list data received from 3 major university hospitals. In addition, a questionnaire regarding document code standardization was created and sent to 268 institutes to establish document classifications and generate a standard coding scheme. A computerized document management system was developed. RESULTS: Only 32% (8 out of 25 institutes) answered that they were able to identify all of the document types and their numbers. In total, 76% of institutes (19 out of 25) answered that a systematic document management system was necessary. Disorganized document files were systemized by classifying them into 8 major groups according to their characteristics: patient test records (T), test quality control (Q), manuals (M), equipment and environment management (E), statistics (S), division administration (A), department administration (R), and others (X). CONCLUSIONS: Our documentation system may serve as a basis for the standardization of documents and the creation of a document management system for all hospital laboratories.

Proposta de documentação fotográfica em motricidade oral / Oral motricity photographic registration proposal

Objetivo: propor um protocolo específico para documentação fotográfica do paciente na área deMotricidade Oral. Método: foi utilizada uma câmera digital fixada em um tripé e foram realizadasfotografias padronizadas corporais e de face. Realizou-se ainda, a teleradiografia lateral contrastadacom bário sobre a língua. Resultados: as fotografias facilitaram a visualização dos nossos resultadosterapêuticos. Conclusão: concluiu-se que a documentação proposta auxilia no diagnóstico e no estudodo prognóstico do paciente, bem como, pode ser utilizado como material auxiliar nas orientaçõesaos responsáveis e ao paciente.

Purpose: to propose a specific protocol for photographic register of Oral Motricity patients. Methods:a digital camera mounted on a tripod was used. Standardized photos of body and face were taken. Atele-radiography modified by using contrast with barium which was spread over the patient’s tonguewas taken. Result: the pictures made easy the visualization of our therapeutic results. Conclusion:so far it is possible to conclude that the proposed documentation helps in the diagnosis process andprognosis analysis, and it may be used as supplementary material for guiding patients and parents onthe best treatment to follow.

Compliance with good practice in prescription writing at outpatient clinics in Saudi Arabia

A sample of prescription orders received from outpatient departments by a hospital pharmacy in Asir, Saudi Arabia, were analysed over 1 year for the essential elements of prescriptions. The prescriber's name, address and signature were on 83.3%, 9.6% and 81.9% of prescriptions respectively. The patient's name, age and sex were on 94.6%, 77.3% and 51.3%. No prescription contained the patient's address and weight. Generic drug names were used in only 15.1% and strength of medication and dose units were included in 26.6% and 55.6% of prescriptions. Most prescriptions [94.0%] had no quantity indicated and had only partial instructions for patient use [90.7%]; the diagnosis was included in about two-thirds. The prescriber's handwriting was illegible in 64.3% of prescriptions. Measures to improve the situation are suggested

A chart audit of postoperative pain assessment and documentation: the first step to implement pain assessment as the fifth vital sign in a University Hospital in Thailand.

PURPOSE: To describe the documentation of pain assessment and management in the first 72 hrs postoperatively. DESIGNS: Retrospective descriptive study MATERIAL AND METHOD: Four hundred and twenty five hospital charts in December 2002 were audited to reveal the quality of postoperative pain assessment and documentation. Scores above 21 from the possible maximum of 28 (75%) were accepted for the review. RESULTS: Nurses documented pain assessment more often than doctors (98.8% vs 29.4%). An assessment of pain intensity using a numerical rating scale (0 to 10) was found in 192 (45.2%) charts, and using a pain descriptor scale in 408 (96%) charts. The documentation of pain both before and after giving analgesics was scarce during the first 3 days postoperatively. Apart from charts that used a patient-controlled analgesia (PCA) technique which had a specific record form, regular pain assessment every 2 to 4 hrs during the first 24 hrs was found in only 2 (0.5%) charts. Pain assessment items which were documented inconsistently and below accepted standards were pain assessment after administration of analgesics, pain assessment every 2 hours in the first 24 hours (day 1), and pain assessment thereafter every 4 hours in the first 24-72 hours (days 2 and 3). The other 4 of 7 audit pain items were documented in higher scores: initial patients' pain intensity and sedation assessment, pain treatment, continuity of pain assessment and pain assessor s name scores. Nevertheless, because of the low total audit score [mean+/-SD = 10.7+/-3 out of 28], it was considered that none of the reviewed charts reflected good quality pain assessment and documentation. CONCLUSION: The present study revealed that the existing practices of pain assessment and documentation were poor. The need for development of regular pain assessment as if pain is the fifth vital sign should be widely emphasized as a part of quality assurance.

How are acute asthma episodes managed and documented in a rapidly developing country?

A retrospective audit of the documentation of 100 children admitted consecutively to hospital with acute asthma was carried out. The aim of the study was to determine the standards of documentation, the treatment regimens and management used and to compare these with the recent International Guidelines on the management of childhood asthma. We wished to assess the adherence to these guidelines. The results indicated: [1] poor documentation, [2] little evidence of a departmental policy regarding a treatment regimen, [3] assessment, management, planning and the use of anti-inflammatory drugs were areas of particular concern. We conclude that there has been little impact from the recent worldwide attention paid to childhood asthma on the actions of those caring for children in this rapidly developing region