Quality of nursing reports Sanatorio Allende cerro in the year 2019

The nursing records are a faithful reflection of the activities that the nursing professional performs of the care provided and how much dedication and commitment he grants in favor of achieving the patient's well-being. They should record not only the vital signs, but also reflect the holistic...

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Autores principales: Suarez, Nora, Caputo, Ana, Cruz, Facundo
Formato: Artículo revista
Lenguaje:Español
Publicado: Sanatorio Allende. Departamento de enfermería 2020
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Acceso en línea:https://revistas.unc.edu.ar/index.php/notasenf/article/view/29154
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record_format ojs
institution Universidad Nacional de Córdoba
institution_str I-10
repository_str R-322
container_title_str Notas de Enfermería
language Español
format Artículo revista
topic Nursing Audit
Nursing Records
Quality Management
Auditoría de Enfermería
Registros de Enfermería
Gestión de la Calidad
Auditoria de Enfermagem
Registros de Enfermagem
Gestão da Qualidade
spellingShingle Nursing Audit
Nursing Records
Quality Management
Auditoría de Enfermería
Registros de Enfermería
Gestión de la Calidad
Auditoria de Enfermagem
Registros de Enfermagem
Gestão da Qualidade
Suarez, Nora
Caputo, Ana
Cruz, Facundo
Quality of nursing reports Sanatorio Allende cerro in the year 2019
topic_facet Nursing Audit
Nursing Records
Quality Management
Auditoría de Enfermería
Registros de Enfermería
Gestión de la Calidad
Auditoria de Enfermagem
Registros de Enfermagem
Gestão da Qualidade
author Suarez, Nora
Caputo, Ana
Cruz, Facundo
author_facet Suarez, Nora
Caputo, Ana
Cruz, Facundo
author_sort Suarez, Nora
title Quality of nursing reports Sanatorio Allende cerro in the year 2019
title_short Quality of nursing reports Sanatorio Allende cerro in the year 2019
title_full Quality of nursing reports Sanatorio Allende cerro in the year 2019
title_fullStr Quality of nursing reports Sanatorio Allende cerro in the year 2019
title_full_unstemmed Quality of nursing reports Sanatorio Allende cerro in the year 2019
title_sort quality of nursing reports sanatorio allende cerro in the year 2019
description The nursing records are a faithful reflection of the activities that the nursing professional performs of the care provided and how much dedication and commitment he grants in favor of achieving the patient's well-being. They should record not only the vital signs, but also reflect the holistic vision that the nurse applies to each of his patients as unique beings. An observational, descriptive, evaluative and retrospective study was carried out, consisting of the records made by the Nursing staff in the clinical records of the patients admitted to the general ward of Sanatorio Allende Cerro in August / September 2019. The selection of the unit of analysis was by simple random sampling. Nursing records were audited for 13 medical records from the moment they entered the institution until they left the institution, constituting a total of 208 Nursing records. This investigation determined that 10 of 15 indicators that were proposed to assess the quality of our records were classified as poorly adequate, reflecting the need to focus attention on improving the quality of our nursing records, since these are documents about professional acts and behaviors that lead to professional and legal responsibilities.
publisher Sanatorio Allende. Departamento de enfermería
publishDate 2020
url https://revistas.unc.edu.ar/index.php/notasenf/article/view/29154
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spelling I10-R322-article-291542020-09-02T21:07:22Z Quality of nursing reports Sanatorio Allende cerro in the year 2019 Calidad de los registros de enfermería Sanatorio Allende cerro en el año 2019 Qualidade dos relatórios de enfermagem Sanatorio Allende cerro no ano 2019 Suarez, Nora Caputo, Ana Cruz, Facundo Nursing Audit Nursing Records Quality Management Auditoría de Enfermería Registros de Enfermería Gestión de la Calidad Auditoria de Enfermagem Registros de Enfermagem Gestão da Qualidade The nursing records are a faithful reflection of the activities that the nursing professional performs of the care provided and how much dedication and commitment he grants in favor of achieving the patient's well-being. They should record not only the vital signs, but also reflect the holistic vision that the nurse applies to each of his patients as unique beings. An observational, descriptive, evaluative and retrospective study was carried out, consisting of the records made by the Nursing staff in the clinical records of the patients admitted to the general ward of Sanatorio Allende Cerro in August / September 2019. The selection of the unit of analysis was by simple random sampling. Nursing records were audited for 13 medical records from the moment they entered the institution until they left the institution, constituting a total of 208 Nursing records. This investigation determined that 10 of 15 indicators that were proposed to assess the quality of our records were classified as poorly adequate, reflecting the need to focus attention on improving the quality of our nursing records, since these are documents about professional acts and behaviors that lead to professional and legal responsibilities. Los registros de enfermería son un fiel reflejo de las actividades que el profesional de enfermería realiza de los cuidados que se brindan y de cuanta dedicación y empeño otorga en favor de lograr el bienestar del paciente. En ellos se debe dejar constancia no solo de los signos vitales, sino también dejar reflejada la visión holística que el enfermero aplica a cada uno de sus pacientes como seres únicos. Se realizó un estudio observacional, descriptivo, evaluativo y retrospectivo, constituido por los registros realizados por el personal de Enfermería en las historias clínicas de los pacientes internados en el internado general del Sanatorio Allende Cerro en Agosto/septiembre de 2019. La selección de la unidad de análisis fue por muestreo aleatorio simple. Se realizó auditoría de los registros de Enfermería de 13 historias clínicas desde el momento de ingreso a la institución hasta el egreso del mismo, constituyendo un total de 208 registros de Enfermería. Esta investigación determinó que 10 de 15 indicadores que se propusieron para valorar la calidad de nuestros registros fueron clasificados como escasamente adecuado, lo que refleja la necesidad de centrar la atención en mejorar la calidad de nuestros registros de enfermería, ya que estos son documentos sobre actos y conductas profesionales que conllevan a responsabilidades de índole profesional y legal. Os registros de enfermagem refletem fielmente as atividades que o profissional de enfermagem realiza dos cuidados prestados e quanta dedicação e comprometimento ele concede em prol do bem-estar do paciente. Eles devem registrar não apenas os sinais vitais, mas também refletir a visão holística que a enfermeira aplica a cada um de seus pacientes como seres únicos. Foi realizado um estudo observacional, descritivo, avaliativo e retrospectivo, composto pelos registros realizados pela equipe de Enfermagem nos prontuários dos pacientes internados na enfermaria geral do Sanatório Allende Cerro em agosto / setembro de 2019. A seleção da unidade de A análise foi realizada por amostragem aleatória simples. Os prontuários de enfermagem foram auditados em 13 prontuários, desde o momento em que entraram na instituição até a saída da instituição, constituindo um total de 208 prontuários. Esta investigação determinou que 10 dos 15 indicadores propostos para avaliar a qualidade de nossos registros foram classificados como inadequados, refletindo a necessidade de focar a atenção na melhoria da qualidade de nossos registros de enfermagem, uma vez que são documentos sobre atos e comportamentos profissionais que conduzem responsabilidades profissionais e legais. Sanatorio Allende. Departamento de enfermería 2020-06-25 info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion application/pdf https://revistas.unc.edu.ar/index.php/notasenf/article/view/29154 10.59843/2618-3692.v20.n35.29154 Notas de Enfermería; Vol. 20 Núm. 35 (2020): Notas de Enfermería; 21-29 2618-3692 1668-8821 10.59843/2618-3692.v20.n35 spa https://revistas.unc.edu.ar/index.php/notasenf/article/view/29154/29988 Derechos de autor 2020 Sanatorio Allende https://creativecommons.org/licenses/by-nc/4.0