Note/records of nursing at school hospital

Abstract

The nursing records consist in the main way to prove the nursing care and the quality of it. The purpose of this study is to investigate the registered nurses and the license practical nurses record in a school- hospital. After fulfilled the ethical requirement, it was analyzed 71 nursing records completed in the first seventy two hours of patient internment in the Intensive Care Unit (ICU) and in the unit where he/she was later transferred. The content of the nursing records was classified into 15 items. The results showed that the number of nursing records was not the ones established by the institution. It was observed that the records of those two professional categories contemplate greater part the same items focusing commonly the biological dimension. Information related to the level of conscience and exam /evaluation results, very important for the ICU patient, was mentioned a small number of times. The psycho-social-spiritual dimension was just recorded once. As conclusion, the nursing records although to be widely discussed, need to be improved.