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[Quality control of nursing records].

Authors: T, Herrero García; A I, Cabrero Cabrero; M R, Burgos Martín; M, García Iglesias; A I, Fernández Herranz;

[Quality control of nursing records].

Abstract

Nursing records are one of the main sources of information about the status of patients admitted to intensive care units. In spite of its importance, this information is not always written down. The objective of this study was to analyze the level of compliance and content of sections related with nursing records, overall and by shifts. A retrospective analysis was made of 14 variables in 358 nursing charts chosen randomly, involving a total of 1.075 shifts. The study variables analyzed were: 1) monitoring, 2) medication, 3) losses, 4) nursing incidents, 5) cures, 6) changes, 7) pressure sores, 8) physical therapy, 9) respirator recordings, and 10) nurses' comments (classified by content into 11) systems, 12) priorities, 13) personal observations, and 14) duplication of information. Nursing records related with medical therapy had a significantly better compliance than records of nursing activities per se. When the variables were analyzed by shifts, the only statistically significant variable was nurses' comments. Systems being the modality most frequently used. We conclude that nursing records, which inform us of the patient's status, showed a good level of compliance. Records of therapeutic medical activities were of better quality than those directly related with nursing activities per se.

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Keywords

Quality Control, Critical Care, Nursing Evaluation Research, Quality Assurance, Health Care, Nursing Records, Nursing Audit, Humans, Retrospective Studies

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
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Average
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