AbstractContinuity of care depends on the sharing of information between professionals, which occurs mainly through completion of patient records. Failure to transmit or receive messages may result in risks to patient safety and reflect on the quality of care provided. Aim: To verify whether the nursing records in the medical records of patients hospitalized in Unidades de Terapia Intensiva Pediátrica (UTI-P - Units of Pediatric Intensive Care) correspond to the safety needs recommended in the literature. Method: This is a descriptive and quantitative study, through documentary research in the nursing records of 92 medical records, in three UTI-P. Results: It was found that in 21.8% of the records there were erasures and in 26.1% there was no complete identification of the care professional. Discussion: Records should not present erasures, as they make it difficult to plan care. In addition, professionals must include their name and registration number at the end of the information noted. Conclusion: Records were adequate according to the safety recommendations, although some aspects are still lacking in relation to nursing standards.
Paes MR, Maftum MA. Communication between nursing team and patients with mental disorder in an emergency service. Cienc Cuid Saude. 2013; 12(1): 55-61.
Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J. 2014; 90(1061): 149-154.
Françolin L, Brito MFP, Gabriel CS, Monteiro TM, Bernardes A. A qualidade dos registros de enfermagem em prontuários de pacientes hospitalizados. Rev. enferm. UERJ.2012; 20(1): 79-83.
Santana JCB, Sousa MA, Soares HC, Avelino KSA. Fatores que influenciam e minimizam os erros na administração de medicamentos pela equipe de enfermagem. Rev. Enferm Revista. 2012; 15(1): 122-37.
Sousa PAF, Dal Sasso GTM, Barra DCC. Contributions of the electronic health records to the safety of intensive care unit patients: an integrative review. Text Context Nursing [internet]. 2012 [Cited 2016 Jan 22] 21(4): 971-9. Available from: http://www.scielo.br/pdf/tce/v21n4/en_30.pdf.
Conselho Federal de Enfermagem. Resolução n. 311, de 08 de fevereiro de 2007. Aprova a Reformulação do Código de Ética dos Profissionais de Enfermagem. Rio de Janeiro; 2007.
Conselho Regional de Enfermagem (SP). Anotações de enfermagem. Junho de 2009.
Rede Brasileira de Enfermagem e Segurança do Paciente. Conselho Regional de Enfermagem (SP). 10 passos para a segurança do paciente. São Paulo; 2010.
Broussard BS, Broussard AB. Using Electronic Communication Safely in Health Care Settings. Nurs Women’s Health. 2013; 17(1): 59-62.
Tannure MC, Lima APS, Oliveira CR, Lima SV, Chianca TCM. Processo de Enfermagem: comparação do registro manual versus eletrônico. J. Health Inform. 2015; 7(3): 69-74.
Azevêdo LMN, Oliveira AG, Malveira FAZ, Valença CN, Costa EO, Germano RM. A visão da equipe de enfermagem sobre seus registros. Rev Rene. 2012; 13(1): 64-73.
Diniz SOS, Silva OS, Figueiredo NMA, Tonini T. Quality of nursing records: analytical reflections on its forms and contents. Rev Enferm UFPE on line [internet]. 2015 Oct 9 [Cited 2016 Jan 15] 9(10): 9616-23. Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/7642/pdf_8765.
Marinič M. The importance of health records. Health. 2015; 7(5): 617-24.
Adeleke IT, Adekanye AO, Onawola KA, Okuku AG, Adefemi SA, Erinle SA., et al. Data quality assessment in healthcare: a 365-day chart review of inpatients’ health records at a Nigerian tertiary hospital. J Am Med Inform Assoc.2012; 19(6): 1039–1042.
Blake-Mowatt C, Lindo JLM, Bennett J. Evaluation of registered nurses' knowledge and practice of documentation at a Jamaican hospital. Int Nurs Rev. 2013; 60(3): 328–334.
Geyer N. How important are nursing records? Prof Nurs Today. 2015; 19(1): 14-16.