Analysis of nursing notes on patients' medical records in a Teaching Hospital

Abstract

This study aims at assessing nursing notes on patients' admission at the clinic of a Teaching Hospital in Montes Claros, State of Minas Gerais. It is a quantitative, descriptive and documentary study carried out from January to December 2008. Data collection was conducted in 253 medical records through probability sampling guided by theoretical references and the current legislation. Theanalyzed notes were in accordance with the standards of the Regional Nursing Council of Minas Gerais. The records conveyed date (96.8%), time (90.5%), in a legible handwriting (87.4%), a full professional identification (76.3%). There was absence of blank spaces (94.1%), comments or erasures (98%), and information unrelated to the client (0.4%). Misspellings were adequately corrected (86.2%) as well as nonstandard abbreviations (5.1%). There were gaps in the nursing notes and/or physical examination records that could jeopardize the medical record functioning as a communication tool. The present study is expected to provide new strategies on education, monitoring and the records systematized assessment to improve care.