Análisis de los registros de enfermería en el área ginecobstetricia de un hospital de la ciudad de Guayaquil.

Abstract

The nursing register consists of a mode of communication between nurses and the entire health team that will collect the necessary information on interventions. Objective: To analyze the nursing records in the gynecobstetrics area of a hospital in the city of Guayaquil. Methodology: Descriptive study, quantitative method with a prospective cross-sectional design. Population: 100 medical records Results: In the dimension of structure, 75% of the records were present, highlighting the indicators that were not fulfilled such as: records with legible handwriting (20%), without alterations (31%) and without spelling mistakes (33%), due to the amount of work during the on-call period. Regarding the dimension of continuity of care, it is evident that 63% are present despite not evidencing records of sociocultural data (100%), annotation of clinical judgments on the response to health problems (100%) and annotations of pending situations (33%). In terms of patient safety, 83% of the clinical records were present; the following stand out in the absent clinical records: the specific characteristics of the drains (80%) were not recorded since they were not necessary because the patients did not have this invasive device, and the few that did have it were recorded normally; the lack of record of the reevaluation of pain (100%). Conclusions: When analyzing the nursing clinical records these were of regular quality with 74% due to the absence of certain indicators of the dimensions of structure, continuity of care and patient safety.