Análisis de los registros de Enfermería en el área de pediatría de un hospital de la ciudad de Guayaquil.

Abstract

Nursing records are considered as a method of communication between health professionals where it allows collecting information about the care and interventions that must be carried out. Objective: To analyze the nursing records in the pediatric area of a hospital in the city of Guayaquil, verifying the quality of patient care. Methodology: Descriptive-quantitative, prospective-cross-sectional design. Population: 100 clinical nursing records from the pediatric area of the Guasmo Sur General Hospital. Results: The evaluation of the dimensions consists of the structure of the nursing record, (35%) of professionals omit to record the hour of admission of the patient, (2%) do not keep a progressive record of the patient's stay, (9% ) misspelling when writing a report, report, note, etc. (4%) does not maintain a good structure, (16%) difficulty in understanding the lyrics. The continuity of care (2%) nurses are presenting a deficit regarding the solution of the patient's needs, (5%) they forget to write down the time of the activities during the shift, (2%) they omit to record the responses of the patients on the interventions that are performed; Lastly, the dimension of safety towards the patient, (1%) do not note the date of the installation of invasive means, (2%) do not correctly place drains and (55%) do not note the reassessment of pain. Conclusions: When analyzing the dimensions of the nursing clinical records, they presented 77% of performance, showing shortcomings in some activities, due to the fact that some professionals do not pertinently comply with the assigned fields.