Abstract
Objective: to analyze the relationship between knowledge and the adequacy of nursing annotations and their determinants. Method: An exploratory, descriptive and quantitative approach, carried out in the Medical Clinic and in the Adult Intensive Care Unit of a Brazilian university hospital. A total of 114 professionals and 41 medical records were included. Results: The professionals had a high mean score of knowledge and a low mean score of adequacy and there was no correlation between them (rs = -0,122; p > 0.05). The knowledge score was higher for professionals graduated in Nursing. The mean score of adequacy was higher for the professional category nurse if packed in Medical Clinic and with the professional that was dissatisfied with the training. Conclusion: there is no relationship between the professional's knowledge about nursing notes and the adequacy of the notes, which leads to serious ethical, legal and patient safety issues.
Highlights
Annotation or nursing record consists of the transcriptions made by Nursing professional in the patient's chart in an orderly and systematic way of the assistance provided by the nursing team to the patient during the period in which he or she is under their care.[1]
It is noteworthy that the Brazilian literature has an extensive number of publications that evaluate and analyze nursing notes in patients' charts, in which the common denominator is the absence of complete and consistent records.[1,2,3,4,8]
The study allowed to conclude that there is no relationship between the knowledge of the professional about nursing notes and the Evaluation of the nursing notes adequacy of the annotations he makes in the patient's chart, that the nursing professionals present a high mean score of knowledge about nursing notes and a low score mean of adequacy of such annotations
Summary
Annotation or nursing record consists of the transcriptions made by Nursing professional in the patient's chart in an orderly and systematic way of the assistance provided by the nursing team to the patient during the period in which he or she is under their care.[1] In this sense, registration is seen as a fundamental means of communication for health teams, since in addition to expressing the actions carried out, it allows continuity of care and legitimates the professional's work through support in ethics and legislation.[2]. The registration is the representation of a fact or an act, relative to the patient's conditions, provided they are expressed in an organized, clear, objective and concise manner,[3] being considered a way of proving and guaranteeing the effectiveness of care and quality of the assistance provided.[4] For the correct accomplishment of nursing notes, it is necessary to know what to note, when, where, how, why, and who should be annotated. Must be duly identified with patient data, plus date and time, and written pen as established by institution.[1]
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