COMPLETENESS OF NURSES’ RECORDS IN THE CARE OF PEOPLE WITH TUBERCULOSIS: A TREND STUDY

Silva Júnior, José Nildo de Barros; Guedes, Haline Costa dos Santos; Nogueira, Jordana de Almeida; Palha, Pedro Fredemir; Nogueira, Matheus Figueiredo; Barrêto, Anne Jaquelyne Roque

doi:10.1590/1980-265X-TCE-2021-0305

Brasil

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Original Article • Texto contexto - enferm. 31 • 2022 • https://doi.org/10.1590/1980-265X-TCE-2021-0305 linkcopy

COMPLETENESS OF NURSES’ RECORDS IN THE CARE OF PEOPLE WITH TUBERCULOSIS: A TREND STUDY

INTEGRIDAD DE LOS REGISTROS DE ENFERMERAS EN EL CUIDADO DE PERSONAS CON TUBERCULOSIS: ESTUDIO DE TENDENCIAS

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: to assess the completeness and tendency of non-completeness of the records of nurses in the care of people with tuberculosis followed up in Primary Health Care.

Method: this is a descriptive, documentary, retrospective study, with quantitative approach, developed in family health units of a municipality in the state of Paraíba. It took place between July and September 2020. A sample of 190 medical records was delineated, selected by sampling in two stages: proportionality and systematic probabilistics. The collected data were analyzed using the R software, assuming a significance level of 5%. Descriptive statistics, Pareto Chart and trend analysis were used.

Results: completeness classification was predominantly “very bad” (76.9%), with a higher percentage of non-completion for the indicators: prejudice (91.1%), preliminary findings (85.2%), absenteeism in consultations (80.8%), family history of tuberculosis (74.7%) and psychosocial aspects. They showed a trend of significant non-completion ascending: lifestyle and conditions of life (p=0.0088) and physical examination (p=0.0352). The only indicator with a trend of significant non-completion descending was Prejudice (p=0.0077).

Conclusion: unsatisfactory completeness and a predominantly ascending trend towards non-completion of records was found, indicating points to be prioritized in public health interventions due to their importance in the production of indicators in tuberculosis management in Primary Health Care that can influence decision-making.

DESCRIPTORS: Nursing; Nursing records; Tuberculosis; Health evaluation; Quality of health care; Primary health care

Indicators	2015	2016	2017	2018	2019	Total	Completeness classification*
Indicators	n^† (%)	n (%)	n (%)	n (%)	n (%)	n (%)	Completeness classification*
Prejudice	12 (100.0)	17 (100.0)	30 (93.8)	50 (89.3)	87.7 (64)	173 (91.1)	Very bad
Propaedeutic findings	10 (83.3)	14 (82.4)	28 (87.5)	48 (85.7)	84.9 (62)	162 (85.2)	Very bad
Absenteeism in consultations	8 (66.7)	15 (88.2)	29 (90.6)	48 (85.7)	74.0 (54)	154 (80.8)	Very bad
Family history of TB	10 (83.3)	15 (88.2)	24 (75.0)	41 (73.2)	71.2 (52)	142 (74.7)	Very bad
Psychosocial aspects	7 (58.3)	11 (64.7)	25 (78.1)	40 (71.4)	75.3 (55)	138 (72.6)	Very bad
Home visit	9 (75.0)	11 (64.7)	25 (78.1)	35 (62.5)	79.5 (58)	138 (72.6)	Very bad
Exam assessment	8 (66.7)	10 (58.8)	22 (68.8)	40 (71.4)	69.9 (51)	131 (68.9)	Very bad
Lifestyle and living conditions	7 (58.3)	10 (58.8)	21 (65.6)	37 (66.1)	71.2 (52)	127 (66.8)	Very bad
Social and family support	6 (50.0)	10 (58.8)	16 (50.0)	28 (50.0)	56.2 (41)	101 (53.2)	Very bad
Treatment	6 (50.0)	10 (58.8)	15 (46.9)	30 (53.6)	53.4 (39)	100 (52.6)	Very bad
Physical examimnation	2 (16.7)	5 (29.4)	11 (34.4)	19 (33.9)	38.4 (28)	65 (34.2)	Bad
Use of other health services	2 (16.7)	7 (41.2)	8 (25.0)	11 (19.6)	26.0 (19)	47 (24.7)	Bad
Clinical manifestations	-	-	2 (6.3)	2 (3.6)	20.5 (15)	19 (10.0)	Regular

Indicators	Model	R²	P-value	Trend	Growth %
Prejudice	y=7214.17 - 3.53x	0.9321	0.0077	Descending	-8.90
Propaedeutic findings	y=-1226.29 + 0.65x	0.2622	0.3780	Ascending	-
Absenteeism in consultations	y=-2359.53 + 1.21x	0.0349	0.7640	Ascending	-
Family history of TB	y=7984.82 + -3.92x	0.7309	0.0649	Descending	-
psychosocial aspects	y=-8139.63 + 4.07x	0.6379	0.1050	Ascending	-
Home visit	y=-1299.60 + 0.68x	0.0188	0.8260	Ascending	-
Exam assessment	y=-3765.18 + 1.90x	0.3674	0.2786	Ascending	-
Lifestyle and living conditions	y=-6612.27 + 3.31x	0.9258	0.0088	Ascending	14.58
Social and family support	y=-673.12 + 0.36x	0.0183	0.8280	Ascending	-
Treatment	y=-270.18 + 0.16x	0.0032	0.9280	Ascending	-
Physical examination	y=-9630.87 + 4.79x	0.8171	0.0352	Ascending	104.89
Use of other health services	y=630.80 -0.30x	0.0025	0.9360	Descending	-
Clinical manifestations	y=-8989.74 + 4.46x	0.6905	0.0813	Ascending	-

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[TFN1] * The completeness classification is measured based on the quantity of records with incomplete fillings;^{15 †}n: number of records with incomplete filling.