Os registros de enfermagem em unidade de internação hospitalar.

Abstract

Introduction: Nursing records are important for a multiprofessional care, allowing communication about the patient's clinical status and the care provided. The process of recording the care provided of the patient, is the medical record involving many factors that may facilitate or hinder this act. Thus, there is a need to know what is the factors and the importance for nursing care. Objective: To investigate the nursing records and the factors that interfere in the achievement and quality of these records in patients hospitalized in a medical and surgical clinic of a teaching hospital located in the interior of the State of Rio Grande do Sul. Method: Convergent Care Survey carried out in a clinical / surgical hospitalization unit, with the nursing team of the morning and afternoon shifts, 11 participants who responded to the form elaborated by the researcher, as a tool for data collection. The observations were also recorded during a voluntary stage. The inspect of the data occurred through thematic analysis. Results and Discussion: The participants of this study pointed out the importance of nursing records for the work process, exposed the various factors that interfere in the achievement and quality of the same and their motivations to perform them. Thus, it was possible to relate this to a literature addressed in the study and points to an overload of work, lack of time and staff quantitative inadequate, interferes in nursing records and with a quality of care provided by this team. Final Thoughts: The meanings of nursing records for most respondents are similar. Factors that interfere with your course can be reduced if attitudes are taken to renew the knowledge and train the workers, so you can count on professionals capable of providing quality assistance.