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[Knowledge and perceptions of the proper completion of nursing records in a tertiary hospital]
Elizabeth Ramos-Silva1, María Guadalupe Nava-Galán, Daniel San-Juan
1Laboratorio de Investigación de Enfermería, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México.
Objective:
To describe the perception, knowledge, status and factors influencing the proper filling of nursing records at a third level of a developing country.
Method:
A cross-sectional quantitative study was performed in a tertiary hospital using two instruments to interview nurses who care for patients on a daily basis. In addition, 100 nursing records were randomly evaluated to determine whether they met the necessary scientific and legal minimum requirements. We used descriptive statistics (mean and standard deviation) to describe the results.
Results:
Ninety nurses participated, 81 (90%) women, and 46.5% (45/90) with a technical level, of whom 92.2% (83/90) recognised the importance of nursing records (83/90; 92.2%). However, 54.4% (49/90) of staff did not know the minimum legal or scientific requirements and did not receive institutional training. The perception of excessive workload was the main factor in the proper filling of the nursing records. Several deficiencies were found in the filling in of nursing records.
Conclusions:
There is a lack of knowledge of the pre-requisites for the proper filling of nursing records, which was reflected in the deficiencies found in the medical records. The workload is an important factor in the proper filling of the nursing records.
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