Análisis de los registros clínicos de enfermería del área de cirugía en un hospital de la ciudad de Guayaquil.

Abstract

The clinical records of health personnel are the main ethical-legal evidence available about the activities and procedures carried out on patients in hospital facilities, which are a standard that must be met and applied. Objective: nursing records in the surgery area of a hospital in the city of Guayaquil. Methodology: descriptive, quantitative, non-experimental, prospective and transversal, the sample corresponded to 100 clinical nursing records. Nursing Clinical Records Quality Questionnaire (CARCE). Among the main results: the general compliance of the records was 84.3%, weaknesses were found: in structure, compliance was 86.6%, 63% recorded the time of admission of the patient to the service, 67% recorded the progressive number of the day of hospital stay, 27% had spelling mistakes, 28% had illegible handwriting, 26% had alterations such as deletions or amendments; in continuity of care, compliance was 75.9%, 10% recorded sociocultural data such as religion, dialect and culture, 65% noted clinical judgments about the patient's responses to real problems and 39% potential problems, 79% noted to educate other health professionals about these real and potential problems; 79% noted the time of nursing interventions, 84% documented the discharge plan, and 47% noted the pain reassessment. Conclusion: a general compliance of 84.3% was obtained, so the criteria of structure, continuity of care and patient safety are not fully met, the main altered indicators were the registration of sociocultural data, the reassessment of pain, pending shift, clinical trials among others.