Quality of nursing reports Sanatorio Allende cerro in the year 2019
DOI:
https://doi.org/10.59843/2618-3692.v20.n35.29154Keywords:
Nursing Audit, Nursing Records, Quality ManagementAbstract
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.
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