HIGHLIGHTS
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High adherence of nurses in recording risk assessment.
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Lack of knowledge and attitude are reasons for low adherence.
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Recurrent training can improve adherence and injury prevention.
ABSTRACT
Objective:
To measure the rate of adherence to the electronic recording of the Munro scale in the perioperative period.
Method:
Retrospective cohort study based on the analysis of medical records in 2022 in a large private philanthropic hospital in the city of São Paulo -BR. The completion data was extracted into an Excel report and analyzed for compliance with the scale.
Results:
22,743 Munro scale records were analyzed, corresponding to 11,892 electronic medical records. The adherence rate was 98.45% in the preoperative phase, 61.73% in the intraoperative phase, and 90.14% in the postoperative phase, with an average rate of 83.44%. Failures to record were related to the absence or partial completion of items on the scale and carrying out the intraor post-operative phase without evaluating the previous phase.
Conclusion:
This study contributes to professional practice by showing the need for educational interventions and improvements in intraoperative processes to increase adherence to risk assessment.
KEYWORDS:
Risk measurement; Perioperative nursing; Electronic health records; Cohort studies; Pressure injury.