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Unsatisfactory completeness of nurses' records in the medical records of users with tuberculosis.
Silva Júnior, José Nildo de Barros; Guedes, Haline Costa Dos Santos; Januário, Dilyane Cabral; Silva, Ana Cristina de Oliveira E; Palha, Pedro Fredemir; Nogueira, Matheus Figueiredo; Barrêto, Anne Jaquelyne Roque.
Afiliação
  • Silva Júnior JNB; Universidade Federal da Paraíba. João Pessoa, Paraíba, Brazil.
  • Guedes HCDS; Universidade Federal da Paraíba. João Pessoa, Paraíba, Brazil.
  • Januário DC; Universidade Federal da Paraíba. João Pessoa, Paraíba, Brazil.
  • Silva ACOE; Universidade Federal da Paraíba. João Pessoa, Paraíba, Brazil.
  • Palha PF; Universidade de São Paulo. Ribeirão Preto, São Paulo, Brazil.
  • Nogueira MF; Universidade Federal de Campina Grande. Cuité, Paraíba, Brazil.
  • Barrêto AJR; Universidade Federal da Paraíba. João Pessoa, Paraíba, Brazil.
Rev Bras Enferm ; 75(3): e20210316, 2021.
Article em En, Pt | MEDLINE | ID: mdl-34852125
OBJECTIVES: to evaluate the completeness of nurses' records on the execution of the nursing process in assistance of tuberculosis patients at Primary Care. METHODS: this was a retrospective documental study, with 190 records in Family Health Units of a city in the state of Paraíba. The data were analyzed according to descriptive statistics, Pareto Diagram, and trend analysis. RESULTS: the overall mean incompleteness of records was 53.01% (DP=26.13). Therefore, the results presented very poor completeness classification related to nursing diagnosis (88.9%), nursing assessment (66.8%), data collection (60.5%), while nursing interventions were classified as regular (11.1%). The nursing diagnosis was the only variable with a decreasing trend of non-completeness. CONCLUSIONS: incompleteness of nurses' records in the medical records of users with tuberculosis. Evaluation strategies, permanent and continuing education are indispensable in the quality of nurses' documentation, directly implying the Systematization of Quality in Nursing Care.
Assuntos

Texto completo: 1 Coleções: 01-internacional Base de dados: MEDLINE Assunto principal: Tuberculose / Enfermeiras e Enfermeiros Tipo de estudo: Observational_studies / Risk_factors_studies Limite: Humans Idioma: En / Pt Revista: Rev Bras Enferm Ano de publicação: 2021 Tipo de documento: Article País de afiliação: Brasil País de publicação: Brasil

Texto completo: 1 Coleções: 01-internacional Base de dados: MEDLINE Assunto principal: Tuberculose / Enfermeiras e Enfermeiros Tipo de estudo: Observational_studies / Risk_factors_studies Limite: Humans Idioma: En / Pt Revista: Rev Bras Enferm Ano de publicação: 2021 Tipo de documento: Article País de afiliação: Brasil País de publicação: Brasil