Quality of nursing work registers: an analysis of prontuaries of patients of the Program of Home Assistance in a university hospital

DOI: 10.15343/0104-7809.2011354395400

Abstract

This study aimed to analyze the quality of nurses’ registers in prontuaries of users of the program of home assistance (PAD)
of a university hospital. Retrospective study, carried through in the PAD of the University Hospital of University of São Paulo, with an
analysis of 64 prontuaries. Data collection was done from February to March of 2011, on the basis of a form having the variables of
nursing registers as regards Diagnosis, Evolution and Nursing Care Prescription on the first visit of nurses to the homes of users. The
results were analyzed by means of descriptive statistics. In the characterization of users, 65.6% were female and 89.1% had ages above
60 years. As regards nurses’ registers concerning the identification of patients and family structure, 96.9% were in compliance with
criteria; the worse indices were linked to conditions of sleep and rest (60.9%) and way of communicating (57.8%). Referring to the
quality of registers, 95.3% presented objectivity, 93.8% contained the date and hour of admission and 92.2% presented the signature
of the nurse. As regards registers in the Diagnostic/Evolution/Prescription of Nursing Care printed form, 92.2% showed conformity in
the identification of the patient, dates and nursing diagnostic. The worse result (20.3%) related to the identification of nursing care
prescription. We concluded that this inquiry made possible the identification of non conformity in nursing registers and offering data
regarding the necessity of improvements in the program.