Abstract

Contexto: As alterações verificadas na documentação em enfermagem suscitaram a realização de um estudo histórico sobre a evolução dos registos de enfermagem, entre 1958, com a criação do Ministério da Saúde e Assistência e 1998, ano da criação da Ordem dos Enfermeiros. Neste sentido, tornou-se pertinente fazer a análise das publicações sobre registos de enfermagem, nas revistas portuguesas, no período em estudo. Objetivo: Identificar e analisar a produção científica sobre registos de enfermagem publicada nas revistas portuguesas de enfermagem, entre 1958 e 1998. Metodologia: Efetuou-se um estudo bibliométrico com a consulta de 504 revistas portuguesas de enfermagem publicadas entre 1958 e 1998, aplicando descritores e critérios de inclusão. Resultados: Obteve-se uma amostra final de 22 artigos relacionados com vários aspetos dos registos de enfermagem. Conclusão: Os registos de enfermagem foram assunto de publicação nas revistas portuguesas a partir de 1984. O número de publicações aumentou à medida que surgiram alterações na profissão de enfermagem. Os registos de enfermagem acompanharam a reconfiguração profissional e são determinantes para a autonomia da profissão.

Highlights

  • Nursing records have been a subject of reflection due to their key role in nurses’ professional performance

  • The study had as inclusion criteria that the consulted journals had to be published in Portugal between 1958 and 1998, and the analyzed articles had to contain the words “records,” “nursing records,” or “documentation” in their title, or other terms related to the documentation of nursing care, such as aspects concerning the application of the nursing process

  • Three articles are translations of foreign authors related to nursing records in patient triage, operating room, and nursing process application

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Summary

Introduction

Nursing records have been a subject of reflection due to their key role in nurses’ professional performance. Nursing records are key to documenting all the steps of the nursing process and the use of a standardized language is essential for their application Their correct implementation allows nurses to improve the care process management and avoid record duplication (Silva et al, 2019). This study was based on journals because the production of professional nursing content and its regular publication in technical journals contribute to disseminating and developing technical and scientific knowledge (Machado, 2014). The changes observed in nursing documentation prompted a historical study on the evolution of nursing records between 1958, when the Ministry of Health and Assistance was created, and 1998, when the Ordem dos Enfermeiros (Portuguese Nursing and Midwifery Regulator) was established. Nursing records have accompanied the nursing career’s professional reconfiguration and are essential for the profession’s autonomy

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