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Objetivo. Describir los registros enfermeros sobre heridas quirúrgicas en pacientes intervenidos en una unidad de Cirugía General y Digestiva. Metodología. Estudio descriptivo transversal. Se revisaron las historias clínicas electrónicas de adultos hospitalizados en una Unidad de Cirugía General y Digestiva que tuvieron una herida quirúrgica durante su estancia en el hospital. Se revisó la documentación de las heridas quirúrgicas en el registro específico de heridas, las notas de los evolutivos de enfermería, los planes de cuidados y el informe de continuidad de cuidados (alta de enfermería). Resultados: muestra de 200 pacientes con una edad media de 58,24 (±17,12) años. En ningún caso se documentó la herida quirúrgica utilizando el registro específico. Las heridas sí se documentaron en las notas del evolutivo de enfermería, con comentarios sobre realización de curas en el 85,5% de los pacientes y sobre el estado o valoración de la herida en el 41%. En el plan de cuidados no se programó ninguna actividad sobre el cuidado de la herida quirúrgica en el 48% de los casos y en el informe de continuidad de cuidados no se refleja la evaluación de la herida quirúrgica en el 85,5% de los casos. Discusión. El registro de las heridas quirúrgicas se realiza de forma incompleta, desigual y poco sistemática, sin utilizar registros específicos estructurados. Detectando las deficiencias de los registros enfermeros sobre las heridas quirúrgicas podemos plantear estrategias para mejorarlos y así incrementar la calidad y seguridad de los cuidados postquirúrgicos. ABSTRACT Objective. To describe nursing records of surgical wounds in patients who underwent surgery in a General and Digestive Surgery Department. Methodology. Cross-sectional descriptive study. Electronic medical records of adult inpatients admitted to a General and Digestive Surgery Department who had a surgical wound during their hospital stay were reviewed. Documentation of surgical wounds in the specific wound register, nursing progress notes, care plans and continuity of care reports (nursing discharge reports) were reviewed. Results. 200 patients with a mean age of 58.24 (±17.12) years were analyzed. There were no surgical wounds documented using the specific register. However, they were documented in the nursing progress notes, with comments on wound/dressing management and wound status or assessment in 85.5% and 41% of patients, respectively. No activity on surgical wound care was scheduled in the 48% of care plans, and surgical wound assessment was not included in the 85,5%m of the continuity of care reports. Discussion. Surgical wound documentation is performed in a incomplete, inconsistent and unsystematic way, without using specific structured registers. By identifying deficiencies in nursing records of surgical wounds, we would be able to suggest strategies to improve them and, therefore, to increase the quality and safety of post-surgery care.

Background: Quality of care depends on the information shared orally during shift handovers and documented in the clinical records. Objective: To analyze the verbal and written information shared in shift handovers and its impact on clinical decision-making in nursing and the continuity of care in a pediatric emergency ward, as well as identify the emerging paradigm for care. Methodology: Qualitative approach, based on Yin's case study process, using three methods: transcription of the shift handover, documented process, and process carried out by the expert. Results: The results show increased sharing of information about unintentional body processes, especially in oral transmission. Although documented data includes more detailed information about adaptive processes, it is incipient for a structured and intentional conception of nursing care. Conclusion: The verbal and written information shared in shift handovers mainly focuses on the disease rather than the individual as a whole. Autonomous nursing information does not address the dimension of the person, the human responses to transitions, and the life processes. [ABSTRACT FROM AUTHOR]

Objective: face and content validation of an instrument for Recording the Nursing Process in the Mobile Emergency Care Service. Method: quantitative study of face and content validation of the instrument by a committee of 21 experts in the field of prehospital mobile emergency care nationwide. A Content Validity Index (CVI) equal to or greater than 0.80 determined validation. Results: a CVI of 0.94 was obtained. Only the item ease of reading, related to appearance, had an index below the established. It was possible to evaluate the 99 nursing interventions listed. Conclusion: the instrument for the Nursing Process Record in the Mobile Emergency Care Service was considered valid and can enable the manual documentation of nursing practice in this setting. [ABSTRACT FROM AUTHOR]

Objective: To assess the quality of records of nurses in the Intensive Care Unit based on Resolution No. 429/2012. Federal Council of Nursing. Methods: Documentary and evaluative study carried out in the Intensive Care Unit of a university hospital in Rio de Janeiro in January 2017. The sample consisted of 312 records. For data collection, an instrument was built based on the determinations of the Resolution No. 429/2012. Results: It was found that 46.8% of the data collection records were incomplete and predominantly focused on the biological dimension of the body and the use of devices without, however, providing consistent information that would support the others stages of the nursing process. The nursing diagnosis based on existing taxonomies was not found in any record. As for the annotation of the actions taken and the evaluation, 68.3% and 85.9%, respectively, were incomplete. Conclusion: In the evaluation of nurses' records, more than 90,0% were incomplete and did not meet the standards determined by Resolution No. 429/2012. Therefore, the evaluated records do not meet the ethical and legal precepts of the profession. [ABSTRACT FROM AUTHOR]

Objective: The recording of data referring to Enteral Nutrition Therapy (ENT) is important to ensure the procedure and systematic communication of care. The objective was to analyze the nursing records regarding the insertion of nasogastric (CNG) and nasoenteral (CNE) catheters, considering the under-recording and non-conformities found in medical records and during patient observation. Methods: observational, cross-sectional study with a quantitative approach, through the application of an instrument to collect data from patients admitted to a University Hospital in Pará between August 2019 and July 2020. Results: 191 insertions of catheters by nurses were identified, of which 43 (22.52%) underreported reinsertion and 148 (77.48%) presented non-conformities. Discussion: Under-registration and non-compliance interfere with the quality of nursing care, weaken patient safety actions, in addition to having legal repercussions. Conclusion: The data presented in this article were essential for the detection of gaps in nursing care. [ABSTRACT FROM AUTHOR]

Copyright of Revista Gaucha de Enfermagem is the property of Revista Gaucha de Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: The clinical history is a record for monitoring the assistance provided by health professionals, which has legal and professional implications and is considered the cornerstone of the hospital information system. This must meet a series of characteristics or requirements in terms of content, order, documentary standardization and legibility which, in nursing practice, allow scientific knowledge as well as clinical practice to be related. Objective: To measure the quality of the nursing records of the Neonatal Intensive Care Unit of a public institution in the City of Buenos Aires, Argentina. Method: An Observational, analytical, and cross-sectional study. 396 nursing records, selected by random sampling, were analyzed. A comparison grid was used to identify compliance with the quality requirements of the registry determined according to legal and institutional requirements. Results: A general compliance with the quality criteria of 71.95% average (minimum compliance) was found, with the priority intervention areas being the recording of nursing diagnoses and the response to nursing care. The shift and the training level showed a relationship with better general indexes in the different dimensions. Conclusions: It is expected that the results of this study can contribute to the identification of areas of intervention to improve the recording of care and activities performed by nursing professionals, while seeking to increase resources to address the issue. [ABSTRACT FROM AUTHOR]

Copyright of Enfermería en Cardiologia is the property of Asociacion Espanola de Enfermeria en Cardiologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Clinical records are a methodological tool based on scientific evidence, they are important and fundamental in the daily work, both to justify the performance of procedures, as well as to hold accountable, support decisions and own activities, it is a vital testimony and document in the clinical and legal field. Objective: To determine the level of scientific knowledge and legal implications of the nursing staff and the level of compliance with the quality of its elaboration. Material and methods: The design of the study is descriptive transversal, by means of a non-probabilistic census sampling, a sample of 46 nurses was obtained. The nursing records assessment instrument and the survey and questionnaire on knowledge of nursing records were used. Descriptive statistics were used. Results: The mean age was 33.39 years (SD = 9.830), 76.1% were female, only 26.1% had good scientific knowledge and 28.3% had good knowledge of legal implications. No relationship was found between the different types of knowledge, sex, shift and academic level (p > 0.05). A non-compliance rate of 80.4% in quality was found. Conclusion: The level of scientific knowledge and legal implications are deficient, as is the level of compliance with the quality of the nursing record regardless of sex, work shift and academic level. [ABSTRACT FROM AUTHOR]

Objective: to analyze the applicability of the Nursing Process in interface with best practices. Method: cross-sectional study, conducted with 146 nurses, using a structured survey questionnaire, applied between May and September 2019, analyzed by descriptive and inferential statistics. Results: of the 146 nurses, 115 (78.8%) performed the Nursing Process, and 73 (50%) applied the five steps of the Nursing Process. Of these 115 prevailed the steps of data collection 110 (95.7%) and implementation of care 104 (90.4%). There was a significant association between the application of the steps of the Nursing Process using information systems and evaluation scales. Some steps of the Process were associated with the use of Standardized Language Systems and nursing theories. Conclusion: the Nursing Process is configured as a strategy to consolidate the best practices, basing the actions on scientific evidence and on the needs of the individual through clinical expertise and qualification of the records. [ABSTRACT FROM AUTHOR]

The present report is the result of a proposal of a didactic model and standard for the accomplishment of the nursing evolution in relation to the patient's admission, as well as its daily accompaniment and dressing evolution in case of skin lesion carrier. It was elaborated, essentially, from the practical experience of the author as clinical teaching supervisor and used as a pilot by a group of academics of a technical nursing course of a public university in the north of Minas Gerais, in the first semester of 2019. It aims to be a standard tool for the teaching of the student in nursing and professional follow-up, as well as to facilitate diagnosis and clinical prognosis and to offer integral, humanized and qualified attention resulting in the clinical recovery of the patient. Also, a well written evolution, with the maximum of clinical variables described, minimizes the chances of an eventual ethical process arising from the provision of care. It is suggested that the evolution model be adopted by academics, both in technical and undergraduate courses, as well as by professors and professionals already trained in order to improve the writing of the evolution in order to provide as much data as possible and also to offer quality care. [ABSTRACT FROM AUTHOR]

Objective: to describe the implementation of the Nursing Process in an intermediate care unit. Method: action research conducted in a public teaching hospital from December 2019 to March 2020 with four training on Nursing Process and Nursing Theories; presentation of nursing process instruments, implementation and follow-up. Changes suggested by the nurses occurred through participant observation and field diary in in loco visits. Results: difficulties in initial filling of instruments were reported, as well as practical inexperience and lack of time and work overload. The benefits mentioned were related to the clear and orderly formatting of the instruments; ease in the application of steps and safety in care practice. Final considerations: the implementation of the Nursing Process in the sector occurred after the identification of the previous knowledge of the nursing team, followed by the survey of the profile of patients, creation of instruments, execution of permanent education of professionals, application and monitoring in the use of the instruments. [ABSTRACT FROM AUTHOR]

Copyright of Revista de Pesquisa: Cuidado é Fundamental is the property of Revista de Pesquisa: Cuidado e Fundamental Online and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista Gaucha de Enfermagem is the property of Revista Gaucha de Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Texto & Contexto Enfermagem is the property of Universidade Federal de Santa Catarina, Programa de Pos-Graduacao de Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Salud, Ciencia y Tecnología is the property of Fundacion Salud, Ciencia y Tecnologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Resumen Introducción: El proceso enfermero (PE) aporta información de los problemas y necesidades de las personas objeto de seguimiento y cuidados. Objetivos: Conocer la evolución del PE dentro de la Historia de Salud DRAGO-AP entre 2011-2018. Metodología: Estudio observacional, descriptivo, transversal en Atención Primaria. Resultados: El 16,8% de los diagnósticos de enfermería (DE) proceden de la valoración por patrones funcionales de salud (PFS) de Marjory Gordon, en los niños se mantiene esta procedencia descendiendo en otros grupos etarios. El 4,55% de los DE presentan indicadores diagnósticos y los que generan planes de cuidados son un 54,71%. Conclusiones: Los DE no proceden exclusivamente de los PFS, y la fase diagnóstica es la más utilizada, presentando diferencias entre grupos etarios.

Introduction: It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC). The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report., Methods: Observational and prospective cohort study. The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI)., Results: The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively. The combination of sources improved CCI agreement by 8%-40% in the overall series and 39.1-89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %-67.5% in operations of greater complexity. The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively., Conclusions: The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions., (Copyright © 2024. Published by Elsevier España, S.L.U.)

Background: The changes observed in nursing documentation prompted a historical study on the evolution of nursing records between 1958, when the Ministry of Health and Assistance was created, and 1998, when the Ordem dos Enfermeiros (Portuguese Nursing and Midwifery Regulator) was established. Thus, the analysis of publications on nursing records in Portuguese journals during this period was considered relevant. Objective: To identify and analyze the scientific production on nursing records published in Portuguese nursing journals between 1958 and 1998. Methodology: A bibliometric study was conducted by consulting 504 Portuguese nursing journals published between 1958 and 1998, using descriptors and inclusion criteria. Results: A final sample of 22 articles related to different aspects of nursing records was obtained. Conclusion: Nursing records have been a publication subject in Portuguese journals since 1984. The number of publications increased as changes occurred in the nursing profession. Nursing records have accompanied the nursing career’s professional reconfiguration and are essential for the profession’s autonomy. [ABSTRACT FROM AUTHOR]

Objective: To analyze nursing records in childcare consultations for children aged 0 to 18 months assisted in a Family Health Unit. Methods: Documentary study, carried out through research in medical records of a Family Health Unit, composed of four family health teams, in the city of Recife, Pernambuco. The sample consisted of 108 medical records of infants aged zero to 18 months. The data were analyzed through descriptive analysis. Results: Regarding the nursing records, it was observed that only 1.9% of the medical records contained all anthropometric measurements, and only 6.5% had the developmental milestones. In the food records, 58.7% of the medical records recorded the duration of exclusive breastfeeding, and when industrialized milk was used, only 6.9% presented its dilution. Regarding the prescription of iron supplementation, 4.6% of the medical records were recorded, of which none described the prescribed supplementation scheme. Regarding immunization, 99.1% had a record about vaccination. Conclusion: There was a gap in the records of nursing consultations in childcare, with the absence of information in the medical records essential for the systematic monitoring of child health. [ABSTRACT FROM AUTHOR]

Objective: To prepare tutorial videos on nursing records, focusing on current legislation. Methods: Research applied to the production of learning objects, carried out within the parameters of technological development of the ADDIE Model (analysis, design, development, implementation and evaluation). The editing of the tutorial videos produced was carried out with the resources of the Vyond software. To make the target audience accessible, the videos were posted on Youtube. Results: A series, consisting of four animated videos, on the legal aspects of nursing records. The subjects covered on the chosen theme are: 1) Generalities; 2) Management documents; 3) Nursing process and; 4) Nursing notes. Conclusion: The creation of videos contributes to professional qualification, however, it is only one of the several actions necessary for this objective to be achieved. [ABSTRACT FROM AUTHOR]

Copyright of Cogitare Enfermagem is the property of Cogitare Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista de Pesquisa: Cuidado é Fundamental is the property of Revista de Pesquisa: Cuidado e Fundamental Online and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista Gaucha de Enfermagem is the property of Revista Gaucha de Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

RESUMEN En Hospitales y Centros de Atención Primaria de Tenerife, en la Historia Clínica Electrónica se ha incluido terminología enfermera, valorando previamente su nivel de información. Se propuso averiguar las dificultades de implantación de la historia clínica electrónica, planteando, ¿Cómo ha evolucionado el sistema de información con la implantación de la historia clínica electrónica del servicio canario de salud? ¿Cuál es la opinión de los expertos sobre el uso del soporte electrónico? Objetivo general: Explorar la evolución de sistemas de información sanitaria en España y analizar el proceso de implantación de la historia clínica electrónica en el Servicio Canario de Salud. Objetivos específicos: Analizar evolución, regulación e hitos históricos de los sistemas de información, Exponer la evolución de la implantación de la Historia Clínica Electrónica en Canarias, Consultar opinión de enfermeros sobre el uso e implantación de la Historia Clínica Electrónica con metodología enfermera y explorar la evolución de los sistemas de información sanitaria, en España. Se realizó estudio cualitativo en dos etapas, revisión bibliográfica y diseño evolutivo, incluyendo variables sobre dificultades de implantación con entrevistas a expertos. Se consultó legislación de interés, concluyendo que contar con un sistema normalizado, mejora la calidad y seguridad del paciente.

Resumen Introducción: Los registros de enfermería son documentos que avalan la calidad y continuidad del cuidado, mejora la comunicación y evita errores durante el cuidado. Objetivo: Describir la percepción de las enfermeras sobre el uso de sus registros para garantizar la continuidad del cuidado en el servicio de medicina interna de un hospital público. Métodos: Investigación cualitativa descriptiva, la muestra fueron 12 enfermeras, se usó la entrevista semiestructura. Resultados: Utilidad e importancia para el equipo de salud; Limitantes e implicancias ético-legales; Necesidad de registros estandarizados e informatizados. Conclusión: Los registros de enfermería llenados con veracidad garantizan la continuidad del cuidado porque son fuente de información para los profesionales del equipo de salud; pero, existen limitantes como la falta de tiempo, la sobrecarga laboral por que se omiten datos que pueden incurrir en implicancias ético-legales, por lo que reconocen la necesidad de formatos estandarizados y digitalizados.

Objective: to evaluate the quality of nursing records carried out in patients' records in a municipal public hospital in the northern region of Brazil. Method: quantitative study, documentary type in medical records of patients who remained hospitalized at least 48 hours. The collection instrument evaluated the quality of the records, as defined by the Federal Nursing Council. Descriptive analyzes were carried out using Stata®13.0. Results: Of the total of 248 medical records, 25.9% were considered complete, 67.1% were incomplete, 6.7% were incorrect and 0.3% were not filled. In more than 90% of the studied registers it was verified that there was no sequential and concise writing, use of technical terminologies and description of the care provided. Conclusions: Nursing records were considered of unsatisfactory quality. As possible ways to be tried it is suggested the use of specific forms for the Systematization of the Nursing Assistance, implantation of the electronic medical record and standardization of acronyms. [ABSTRACT FROM AUTHOR]

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Objective: to report the development of an audit technology for applicability of the steps of the Nursing Process in a hospital in western Santa Catarina. Method: experience report involving nurses and nursing professors. Results: it was possible to structure a flowchart describing the step-by-step of the audit procedures in the hospital institution, as well as showing the indicators used to analyze the aspects referred to in the instrument of audit. The data were analyzed and discussed with the nurses in "conversation wheels" aiming at the improvement. Conclusion: the experience allowed realizing that, for the implementation of the Nursing Process in the clinical practice of health services, it is vital to establish the audit process jointly. The deployment of a structured committee in the hospital of study, concerned with developing management technologies for qualification of care and structured in a collective and participative way, was crucial to the success of actions. [ABSTRACT FROM AUTHOR]

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Estudio cualitativo con enfoque de investigación acción participación tuvo como objetivo: Analizar y describir las anotaciones de enfermería; e Incorporar las de tipo SOAPIE a través del proceso participativo en el servicio de Pediatría del Hospital las Mercedes, 2016. Se entrevistó a 10 enfermeras y se utilizó la guía de observación en las anotaciones de enfermería del servicio durante dos meses, aplicándola antes y después de la intervención. Prevalecieron los criterios de rigor científico y los principios de la bioética personalista; para el procesamiento de datos se usó el análisis de contenido temático, emergiendo las siguientes categorías: Realizando anotaciones narrativas y descriptivas incompletas por desconocimiento de anotaciones SOAPIE y carencia de formatos; Reconociendo la importancia de las anotaciones tipo SOAPIE; Realizando las anotaciones tipo SOAPIE a través del formato sistematizado. Concluyendo que las anotaciones de enfermería son documentos que permiten evidenciar el cuidado brindado por la enfermera, para lo cual se diseñó un formato donde se escribieron las anotaciones tipo SOAPIE establecidas en normativas del MINSA, con lo cual resultó la mejor forma de evidenciar todo el cuidado que realiza la enfermera durante su turno.

Objective: To identify and analyze scientific articles describing the systematization of nursing care (SAE) in the Postanesthetic Care Units (PACU). Methodology: integrative review of the literature conducted in May 2019, through consultation of the databases and/or portals US National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Scopus, Web of Science and in the portals of the Virtual Health Library (VHL). Results: two articles composed the sample of this review, which proposed to identify SAE registration models in the PACU. Conclusion: There is a need for studies that propose instruments for SAE in the PACU. The evidence identified has elements that contribute to the nature of the categories of nursing diagnoses, which may represent the care needs of patients in PACU. [ABSTRACT FROM AUTHOR]

Copyright of Enfermagem Brasil is the property of Atlantica Editora and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista de Enfermagem e Atenção à Saúde (REAS) is the property of Revista de Enfermagem e Atencao a Saude - Reas and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: To analyze the quality of the nursing records on patients' records. Methodology: A descriptive study of a quantitative approach performed in a university hospital of Salvador, Bahia, Brazil, between the months of September 2017 and May 2018, from quality indicators of the nursing registers on patients' records. A structured instrument was used for data collection. The analysis was descriptive; it was used the absolute and relative frequency of the indicators. Result: Among the 203 patients' records analyzed, the percentage of correct identification of patients, with full name and number of the clinical record was of over 90%. Nevertheless, there was a weakness in checking medical and nursing prescriptions, as well as in the justification for not checking prescribed items. Conclusion: The quality of the nursing registers partially follows the recommendations of the Federal Council of Nursing. The results suggest the need for constant practice of educational programs for strengthening actions towards performing nursing registers with excellency. [ABSTRACT FROM AUTHOR]

Copyright of Acta Paulista de Enfermagem is the property of Universidade Federal de Sao Paulo, Escola Paulista de Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Acta Paulista de Enfermagem is the property of Universidade Federal de Sao Paulo, Escola Paulista de Enfermagem and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista de Pesquisa: Cuidado é Fundamental is the property of Revista de Pesquisa: Cuidado e Fundamental Online and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Aim: To analyze undergraduated nursing students records on needle catheter peripheral venous puncture. Method: Quantitative, descriptive study, enrolled 76 undergraduated nursing students at a public university, from february through march 2014. Data collecting took place at simulated scenario and procedure records were taken with structured instrument. Descriptive analysis performed. Results: About fragilities, 100% of the students did not make catheter fixation notes; adverse events information (87,3%), used device (85%) and puncture reason (84,1%) were predominantly absent. Adequate date, time and identification records were positive highlights. Conclusion: Technique registration discrepancies were identified, with essential information absent or incomplete. Subject matter should be worked in association between theory and practice, focusing competence development at teaching environment and nursing assistance locations. [ABSTRACT FROM AUTHOR]

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Copyright of Ciencia, Cuidado e Saude is the property of Universidade Estadual de Maringa and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

En este escrito se hace una reflexión sobre los conceptos e importancia de las notas de enfermería; muestra que su importancia radica en que favorecen la comunicación entre el equipo interdisciplinario, suministrando una información clara, precisa y detallada del acto de cuidado, para articular el proceso de atención de enfermería. Se expone un reflejo de la realidad en cuanto a la delegación de funciones propias de la profesión, y evidencia la falta de liderazgo y pérdida de autonomía por parte del profesional. Las anotaciones de enfermería son tomadas como el soporte escrito del cuidado brindado en la práctica profesional. Las autoras hacen una invitación a retomar la fundamentación teórica y metodológica de las notas de enfermería y su re-significación, en aras de dar visibilidad y fortalecer el liderazgo y gestión del acto de cuidar.