Research Article
Volume 2 Issue 11 - 2020
Nursing Records: Factors that May Contribute to Deficiencies in Reports on Wound Dressings
Lucimeire Fermino Lemos*, Maria Alves Barbosa, Alessandra Rodrigues De Almeida Lima, Regiane Aparecida Da Silva Souza Barreto, Karina Suzuki and Marinésia Aparecida Do Prado
Universidade Federal de Goiás, Brazil
*Corresponding Author: Lucimeire Fermino Lemos, Universidade Federal de Goiás, Brazil..
Received: April 10, 2020; Published: October 22, 2020




Abstract

Introduction: Defined as the act of transcribing, records support research in several areas. In health care the nursing team produces a lot of information about the patient care and is responsible for more than 50% of the information contained in the patient’s medical record. The need to register complete and concise records is underscored.

Objective: Identify factors that may contribute to deficiencies in records of wound dressings made by nurses.

Method: Descriptive exploratory study with a quantitative approach, carried out in a teaching hospital located in the Centre-West Region of Brazil. Using a questionnaire containing open and closed questions, 56 healthcare nurses were interviewed.

Results: As for the execution of registration of nursing actions in medical records, it was found that less than half of them (48.2%) reported some difficulty. Most participants reported difficulties motivated by personal, operational and professional preparation aspects, in reporting dressings. Lack of time and human resource, overwork, difficulties in accessing the patient's medical record, interruptions in procedures, and lack of guidance are factors that contribute to deficiency or absence of records on dressings.

Conclusion: There were factors for the absence of information in records among the studied group. The identification of these motives and their resolutions are the path to offering differentiated qualified service. Continuing education measures are recommended for the qualification of those responsible for the records, as well as a reorganization of activities carried out by nurses in the inpatient units.

Keywords: Records Control; Nursing Records; Nursing

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Citation: Lucimeire Fermino Lemos., et al. “Nursing Records: Factors that May Contribute to Deficiencies in Reports on Wound Dressings”. EC Nursing and Healthcare 2.11 (2020): 111-117.

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