A quality assessment of immediate postoperative nursing care documentation
DOI:
https://doi.org/10.5327/Z1414-4425201800010005Abstract
Objective: To assess the quality of immediate postoperative nursing care documentation in reference units in the state of Pernambuco,
Brazil. Method: A descriptive, cross-sectional, documental and comparison study with a qualitative approach performed in three hospitals (A, B, C).
The sample was comprised of 130 health records from October to November 2015 and the data was collected from a semi-structured form.
Results: The records, checking and evaluation of procedures were performed differently in each of the assessed hospitals. In hospital A, there was
no recording of vital signs, whereas in hospitals B and C, there was. In institutions A and C, in 100% of the cases, there was no calculation performed
that used the Aldrete-Kroulik scale. The three institutions demonstrated good results with legible documentation that did not have many erased
items. Conclusion: It was found that the hospitals analyzed don’t meet the standards proposed by the predominant postoperative care literature
regarding nursing documentation.
References
Seignemartin BA, de Jesus LR, Vergílio MST, Silva EM. Evaluation
of the quality of nursing records in the emergency department
of a teaching hospital. Rev Rede Enferm Nord [Internet]. 2013
[acesso em 2015 dez 8];14(6):1123-32. Disponível em: http://
www.revistarene.ufc.br/revista/index.php/revista/article/
viewFile/1352/pdf_1
Maziero VG, Vannuchi MTO, Haddad M do CL, Vituri DW, Tada
CN. Quality control of patients’ monitoring records in a
university hospital. Reme Rev Min Enferm [Internet]. 2013
[acesso em 2015 dez 8];17(1):171-6. Disponível em: http://
www.reme.org.br/content/imagebank/pdf/en_v17n1a14.pdf
DOI: 10.5935/1415-2762.20130014
Valença CN, de Azevedo LMN, Oliveira AG, de Medeiros SSA,
Malveira FAS, Germano RM. The scientific literature on nursing audit
and quality of records. Rev Pesqui Cuid Fundam [Internet]. 2013
[acesso em 2015 dez 8];5(5):69-76. Disponível em: http://www.seer.
unirio.br/index.php/cuidadofundamental/article/view/1617/pdf_995
DOI: 10.9789/2175-5361.2013v5n5esp69
Cecílio AAS, Peniche A de CG, Popov DCS. Analysis of blood pressure
records at post-anesthesia recovery room. Acta Paul Enferm.
;27(3):249-54. http://dx.doi.org/10.1590/1982-0194201400042
de Lima LB, Rabelo ER. Nursing workload in the postanesthesia care
unit. Acta Paul Enferm. 2013;26(2):116-22. http://dx.doi.org/10.1590/
S0103-21002013000200003
Medronho RA. Epidemiologia. 2ª ed. São Paulo: Atheneu; 2008.
de Cunha AL SM, Peniche A de CG. Content validity of an instrument
to document recovery of patients in post anesthesia care unit.
Acta Paul Enferm. 2007;20(2):151-60. http://dx.doi.org/10.1590/
S0103-21002007000200007
Brasil. Ministério da Saúde. Política Nacional de Atenção Integral
à Saúde do Homem: princípios e diretrizes [Internet]. Brasília:
Ministério da Saúde; 2009 [acesso em 2015 dez 8]. Disponível em:
http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_
atencao_homem.pdf
Miranda TMM, Petriccione S, Ferracini FT, Borges Filho WM.
Interventions performed by the clinical pharmacist in the emergency
department. Einstein (São Paulo). 2012;10(1):74-8. http://dx.doi.
org/10.1590/S1679-45082012000100015
Brasil. Ministério da Saúde (MS). Protocolo de Segurança na prescrição,
uso e administração de medicamentos. Anexo 3 da Portaria MS nº
095, de 24 de setembro de 2013. 2013 [acesso em 2015 dez 8].
Disponível em: http://www.hospitalsantalucinda.com.br/downloads/
prot_meficamentos.pdf
Tavares TS, de Castro AS, Figueiredo ARFF, dos Reis
DC. Evaluation of the implementation of the systematic
organization of nursing care in a pediatric ward. Rev Min
Enferm [Internet]. 2013 [acesso em 2015 dez 8];17(2):42-50.
Disponível em: http://www.reme.org.br/artigo/detalhes/650
http://www.dx.doi.org/10.5935/1415-2762.20130022
de Oliveira JMA, Silva AMF, Cardoso S de B, Lima FF, Zierer M de S,
Carvalho ML. Postoperative complications of cardiovascular surgery
with cardiopulmonary by-pass. Rev Interdiscip. 2015 [acesso em
dez 8];8:9-15. Disponível em: http://revistainterdisciplinar.
uninovafapi.edu.br/index.php/revinter/article/view/584/pdf_177
Giordani AT, Sonobe HM, Ezaias GM, Valério MA, Barra
MR, Stadler DV. Profile of surgical patients treated in a public
hospital. Rev Enferm UFPE on line [Internet]. 2015 [acesso
em 2015 dez 8];9(1):54-61. Disponível em: https://periodicos.
ufpe.br/revistas/revistaenfermagem/article/view/10306/10974
DOI: 10.5205/reuol.6817-60679-1-ED.0901201508
Ribeiro M, Peniche A de CG, Silva S. Complicações na sala de
recuperação anestésica, fatores de risco e intervenções de enfermagem:
revisão integrativa. Rev SOBECC. 2017;22(4):218-29. http://dx.doi.
org/10.5327/Z1414-4425201700040007
Associação Brasileira de Enfermeiros de Centro Cirúrgico, Recuperação
Anestésica e Centro de Material e Esterilização (SOBECC). Diretrizes
de práticas em enfermagem cirúrgica e processamento de produtos
para a saúde. 7ª ed. Barueri: Manole; São Paulo: SOBECC; 2017.
Welte LVT, Fonseca LF. Patient recovery assessment in
post-operative recovery room in absence of anesthetic. J
Nurs UFPE on line [Internet]. 2016 [acesso em 2016 out
;10(6):2091-9. Disponível em: https://periodicos.ufpe.
br/revistas/revistaenfermagem/article/view/11222/12807
DOI: 10.5205/reuol.9199-80250-1-SM1006201623
V olquind D, Fellini RT, Schnor OH, Flores RPG, Londero BB. Influência
da escala de Aldrete e Kroulik nas estratégias de gestão da sala de
recuperação pós-anestésica. Rev Adm Hosp [Internet]. 2014 [acesso em
dez 8];11(4):99-104. http://dx.doi.org/10.21450/rahis.v11i1.1987
Silva JJA, Grossi ACMA, Haddad MDCLM, Marcon SSS. Avaliação da
qualidade das anotações de enfermagem em unidade semi-intensiva.
Esc Anna Nery. 2012;16(3):577-82. http://dx.doi.org/10.1590/
S1414-81452012000300021
Conselho Federal de Enfermagem (COFEn). Resolução COFEN n.
/2007. Dispõe sobre o Código de Ética dos Profissionais de
Enfermagem. Rio de Janeiro: COFEn; 2007 [acesso em 2015 dez 8].
Disponível em: https://www.diariodasleis.com.br/busca/exibelink.
php?numlink=1-39-34-2007-02-09-311
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