Unsatisfactory completeness of nurses' records in the medical records of users with tuberculosis.
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.
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