Efeito de um instrumento padronizado na qualidade de registros de enfermeiros

Abstract

Objective: to evaluate the effect of the implementation of an instrument based on diagnostic standardized language systems, interventions and results on the quality ofnurses' records. Methods: a quasi-experimental study that compared the quality of nurses' records through the Quality of Diagnosis, Interventions and Outcomes in medical records of patients hospitalized in cardiovascular units before and after the implementation of astandardized instrument. Results: there was a significant improvement in the quality of records after the use of the instrument in the "diagnosis as a process" (p=0.018), "diagnosis as a product" (p=0.019) and "Nursing outcomes" (p<0.001) dimensions. The "Nursingintervention" dimension showed no statistically significant difference, but obtained an increase in the score at post-intervention time. Despite the improvement in the qualityof the records, the mean of the total score remained low after implementation of the instrument (14.8±5.7 vs. 29.0±10.5; p=0.003). Conclusion: the use of an instrument based on diagnosis standardized language systems, interventions and results has improved the quality of nurses' records in cardiovascular units and should be considered an important tool for improving the documentation on patient records.