[Quality control of nursing records]

Nursing records are one of the main sources of information about the status of patients admitted to intensive care units. In spite of its importance, this information is not always written down. The objective of this study was to analyze the level of compliance and content of sections related with nursing records, overall and by shifts. A retrospective analysis was made of 14 variables in 358 nursing charts chosen randomly, involving a total of 1.075 shifts. The study variables analyzed were: 1) monitoring, 2) medication, 3) losses, 4) nursing incidents, 5) cures, 6) changes, 7) pressure sores, 8) physical therapy, 9) respirator recordings, and 10) nurses' comments (classified by content into 11) systems, 12) priorities, 13) personal observations, and 14) duplication of information. Nursing records related with medical therapy had a significantly better compliance than records of nursing activities per se. When the variables were analyzed by shifts, the only statistically significant variable was nurses' comments. Systems being the modality most frequently used. We conclude that nursing records, which inform us of the patient's status, showed a good level of compliance. Records of therapeutic medical activities were of better quality than those directly related with nursing activities per se.