Análisis de los registros clínicos de enfermería del área de ginecobstetricia de un hospital de la ciudad de Guayaquil.

Abstract

Nursing records are elementary instruments in health care, they represent par excellence a means of communication and coordination between health professionals, their correct performance allows continuity of care and patient safety, they are also integrated into the clinical history. of the patient, so it is necessary to do them with such scientific rigor to guarantee their quality. Objective. - To analyze the quality of nursing records in the obstetrics and gynecology area of a hospital in the city of Guayaquil. The Methodology was descriptive, quantitative approach, observational design, prospective and cross-sectional cut, where 100 clinical nursing records were analyzed. Results. - Structure of the record: 87.3% register without erasures or amendments, 62.7% of the cases do not make the records with legible handwriting, in 64.7% the records contain misspellings and 62. 7% do not use technical language or scientific terminology. Continuity of care: 94.1% record the patient's responses to Nursing interventions, 72.5% do not document the home discharge plan, and 60.8% do not record pending situations for the next shift. Patient safety: 91.2% record the date of installation of invasive means, 97.1% note the specific characteristics of the surgical wound, 94.1% record the assessment of pain. 73.5% do not record data about the reassessment of the patient's pain, 55% do not record the characteristics of the patient's drains. Conclusions. - According to the dimensions observed, there are insufficiencies in terms of the structure of the registry, however, in the continuity of care and patient safety there are a greater number of relevant positive aspects.