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Documentation of the nursing process in public health institutions
Oswalcir Almeida de Azevedo1, Érika de Souza Guedes1, Sandra Alves Neves Araújo2
1Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem na Saúde do Adulto, São Paulo, SP, Brasil.
Objective:
To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health.
Method:
A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations.
Results:
Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors.
Conclusion:
Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.
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