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[Evaluation of nursing notes based on the nursing process].

K Ochoa-Vigo1, A E Pace, L A Rossi

  • 1Escolas de Enfermagem de São Paulo e Ribeirão Preto, Universidade de São Paulo. kovpe@bol.com.br

Revista Da Escola De Enfermagem Da U S P
|December 18, 2002
PubMed
Summary
This summary is machine-generated.

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This study analyzed nursing notes, finding nurses

Area of Science:

  • Nursing
  • Healthcare Informatics

Context:

  • Retrospective analysis of nursing notations in a specialized care unit.
  • Focus on documentation within the Nursing Process framework.

Purpose:

  • To evaluate the quality and characteristics of nursing notations.
  • To differentiate documentation practices between nurses and nursing assistants.

Summary:

  • Nursing assistants produced more extensive, less specific notes.
  • Nurses' notes were generally more legible and objective.
  • Identified areas for improvement in nursing documentation.

Impact:

  • Highlights the need for enhanced objectivity and completeness in nursing records.
  • Informs strategies for improving nursing documentation quality.

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  • Supports better communication and continuity of patient care through improved records.