ABSTRACT
Objective:
To evaluate the quality of the records of healing performed by nursing records.
Method:
Descriptive study with retrospective documentary analysis. This study was conducted in adult Intensive Care Unit of the Hospital of Samuel Libanius.
Results:
65 (65%) of annotations not present in this type of tissue lesion, 85 (85%) had no type of exudate, 100 (100%) indicated no measurement of the wound and in 80 (80%), the appearance of margin and center of the lesion were not recorded. 100 (100%) of the notes were with abbreviation, 59 (59%) had no clarity of notes and 80 (80%) had grammatical errors and language of 80 (80%) contained incorrect errata and technical terminologies. 75 (75%) of nursing prescriptions were not checked and in 54 (54%) of the notes the letter was not legible.
Conclusion:
In this study the authors concluded that the quality of the ratings of nursing care are limited and inadequate.
Keywords:
Quality of Health Care; Quality Assurance; Health Care; Nursing; Bandages