Análisis de los registros clínicos de enfermería del área de medicina interna en un hospital de la ciudad de Guayaquil.

Abstract

Clinical records are documents used to record care-related information systematically and accurately during patient care. Objective: To analyze the clinical nursing records of the internal medicine area in a hospital in the city of Guayaquil. Methodology: descriptive, quantitative, prospective, crosssectional study. Technique: Indirect observation. Instrument: CARCE check sheet. Population and sample: 100 clinical nursing records from the internal medicine area. Results: Structure of the records. There was an absence of the time of admission of the patient to the service (97.00%) and the progressive number of the day of the hospital stay (65.00%). For continuity of patient care: There was an absence of records of the patient's socio-cultural data (religion, language-dialect, culture) (99.00%), documentation of the home discharge plan (94.00%) and a lack of recording clinical judgments about responses to potential health problems (93.00%). And for patient safety: There was no annotation of the pain reassessment (100.00%); nor the specific characteristics of the drains from the registry (95.00%); and little documentation of the educational support provided to the patient and family (55.00%); Conclusion: the percentage of compliance with clinical records for the structure was 68%, for continuity of care 51% and for patient safety 76%. A record of 65% was found to be deficient. These could have a significant impact on the quality and accuracy of patient care, which could negatively affect decision making.