Gestão da Informação e Registros de Enfermagem

Abstract

This research had as objective to analyze the quality of the notations of nursing concerning the cares of the surgical patient. The nursing notations prove and deserve attention for majority of the professionals for the success of the assistance to the patients. The handbooks are important documents that they evaluate all the evolution of the patient in the Hospital Unit. An efficient management is essential for the hospitals that they aim at to eliminate wastefulnesses that do not add value for the patient and the institution. The management of the information enters in the process of the nursing as mechanism that the aid to provide the quality with the information registered in the handbook being solved the detected problems as unreadable letters, disorganization of the events, making it difficult the recovery of the patient. The registers or notations of nursing consist of the media for the team as to supply information the research, to serve of legal ethical instrument, evaluating the quality of the cares. To have an assistance of quality with security an efficient communication channel must be had, allowing the team to transmit and to receive information from clear and correct form. A exploratória, qualitative and quantitative research was developed combined with case study. For attainment of data, an interview was made after that was used subjective questionnaire with questions that directed the team of health for the subject that guided the research. The research made possible a great learning concerning the importance of the carried through registers of nursing of clear and coherent form, making possible security in the quality of the cares given to the patient in surgical center. The quality of the registers is not satisfactory, in accordance with the research and with regard to the analyzed contents they need improvements in the nursing registers, qualifications for the professionals, communication between the teams, attention and preparation in the cares to the surgical patient giving the necessary cares.