Evaluation of care records related to emotional safety

Abstract

the Clinical History constitutes one of the sources of information on health care provided by nursing professionals through the registry, as a tool for daily nursing care, which allows the actions carried out to be sealed. All this entails a responsibility at a professional and legal level, which requires a practice based on scientific, ethical and legal rigor. The objective was to evaluate the implementation of the registry of care related to emotional security in patients hospitalized in the Coronary Unit service. An evaluative investigation was carried out, using the electronic nursing records of the medical records. The dimensions studied were seven: such as the Link, Environmental, technical expertise, Communicational, Body, Specific and Affective Assistance. Results: security care is not recorded in all the reports, the night shift presents more emotional care records, second in the morning shift and a lower percentage in the afternoon shift. The environmental dimension was the highest recorded and the least recorded was the dimension of expertise. Conclusions: It is recommended to continue with the training to raise awareness about the importance of registering as it is the evidence of the care provided. These records demonstrate the autonomous role of nursing, and the assessment and care of the emotional aspects of each one of the assisted patients.