Análisis de los registros clínicos de enfermería del área de pediatría de un Hospital de Guayaquil.

Abstract

Nursing records in the pediatric area are essential for the care and follow-up of the pediatric patient since it helps health professionals to carry out exhaustive follow-up throughout hospital care. Objective: To analyze the clinical nursing records of the pediatric area in a hospital in the city of Guayaquil. Methodology: descriptive study; quantitative method and prospective cross-sectional design. Technique: Indirect observation. Instrument: CARCE check sheet. Population and sample: 100 clinical nursing records. Results: In the Structure dimension of the record, 76% presence was obtained, an absence of 26% was evident. Emphasizing those such as not writing down the date (100%); time of patient admission (97%) and subsequent date of the day of hospitalization (50%). Regarding the dimension of Continuity of care, it was 55%; highlighting those such as the absence of socio-cultural data records (100%); absence of clinical judgments about responses to health problems (99%); documentation of the home discharge plan (98%); and clinical judgments about patient responses to potential health problems (96%). While for patient safety 92%; specifically, the lack of recording in the annotation of the pain reassessment (100%). Conclusions: Nursing records were registered in 75%, which gives an average quality of records, but generally seeks to achieve 100% compliance in clinical documentation to guarantee safe and high-quality care.