CAMBIO HACIA LOS REGISTROS DE ENFERMERÍA SEGÚN INSTRUMENTO NORMALIZADO. POLICLÍNICA PEDIÁTRICA DE LA CIUDAD DE MONTEVIDEO.

Héctor Rosso

doi:10.22235/ech.v4i1.513

Authors

Héctor Rosso Centro Hospitalario Pereira Rossell.

DOI:

https://doi.org/10.22235/ech.v4i1.513

Keywords:

Nursing Care, Clinical Records, Nursing Records.

Abstract

Nursing records are a part of the healthcare work undertaken by nurses while caring for the healthcare needs of the population. It is necessary to be aware of the importance of good quality records during the care process, as well as of the legal
repercussions they can bring. The problem that guided this study was the lack of nursing records, which generated communication difficulties among health staff. The study was carried out in the pediatric area of a national referral hospital,by implementing a records form and measuring the quality of what was recorded. The study was conducted from March 30th to May 31st, 2011. In the clinical record, there was no specific place or section for the nursing records. The standardization allows a proper understanding of the phenomenon that occurs in the users during the care process. It is important to count on the nursing records, adapted to the different services and institutions, whether in paper or digital format. The recording instrument allows individualizing the nursing care in a holistic way, allowing the use of a common language to improve the communication between professionals, to avoid errors and omissions in writing, to facilitate risk management and making the care management visible. Furthermore, it constitutes a tool for research and it enriches the nursing discipline.

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