Quality of the electronic nursing records of a highly complex hospital in the city of Corrientes. Year 2021.
DOI:
https://doi.org/10.59843/2618-3692.v24.n42.42639Keywords:
quality of health technology, electronic health record, information managementAbstract
Introduction: recording the care that nursing provides daily to patients is an essential task, both for providing adequate health quality and for the development of the profession. Objective: the objective was to identify the quality of the electronic nursing records of a highly complex hospital in the city of Corrientes. Methodology: a cross-sectional descriptive quantitative study was carried out where 133 digital medical records were reviewed using an adapted and previously validated tool. Results: specifically, the patient identification variable obtained good quality, regarding the assessment record, it was identified that 92% of the medical records registered less than 6 indicators, a poor quality, and the remaining 8% registered regular quality, and the variable interventions obtained a poor quality with 87% registering the indicators. Conclusion: in the results of the investigation, it was concluded that the quality of the electronic nursing records of the hospital's intensive care service is of poor quality compared to the electronic record of the nursing process.
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