Failures in nursing notes that interfere with the quality of care: integrative review
International Journal of Development Research
Failures in nursing notes that interfere with the quality of care: integrative review
Received 07th August, 2021; Received in revised form 18th September, 2021; Accepted 23rd October, 2021; Published online 30th October, 2021
Copyright © 2021, Maurício José Almeida Morais et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: The nursing team is involved in all the stages of the assistance given to the patient, which generates a high quantity of registers related to the procedures. Objective: To analyze the failures in the nursing notes that interfere with the quality of care according to the literature. Methodology: This is Integrative Literature Review research in the LILAC, BDENF and SCIELO electronic library databases from original articles, in Portuguese language published in the period from 2010 to 2020. Results: The main flaws identified were: deficient content, which did not express the reality of the patients and the nursing care provided; absence of registration values of signs and symptoms, intercurrences and response to the nursing prescription. As for textual aesthetics, author identification and checking of items, the results were unsatisfactory. Conclusion: Hospital institutions need to invest more in training and health education courses for nursing professionals, since they are responsible for most of the records in patients' charts.
