Análisis de los registros clínicos de enfermería del área de medicina interna de un hospital de la ciudad de Guayaquil.

Abstract

Introduction: nursing records are legal reports that consist of actions that have been carried out by the nurse on the patient. Therefore, the objective is to analyze the nursing records in the internal medicine area of a hospital in the city of Guayaquil. Methodology: the work is descriptive, quantitative, retrospective, cross-sectional; applying a check sheet through the review of clinical records and the CARCE evaluation instrument. Population and sample: 100 nursing clinical records from the internal medicine area. Results: The prevailing values are detailed: In the structure; 86% absence of alterations, 63% do not apply technical language, 90% do not place identification. Regarding continuity; 99% complete vital signs, 87% do not record the data of the focused and generalized assessment, 78% lack sociocultural data of the patient, 99% record pending situations, 97% do not record the time, 94% do not write the home discharge plan. In patient safety; 71% identify the correct patient, 51%/59% record the pain assessment, 51%/98% do not place the characteristics of the site of insertion of invasive means, however, if the date of placement is present; 67%/79% absence the specific characteristics of the surgical wound and the same of the drains, 93%/91% record the safety measures in risk of falls and pressure ulcers. Conclusions: When analyzing the nursing records; we found that 58% of the total reports are not correctly filled out; they do not comply with structure, safety and continuity of care offered to patients.