Abstract

Introduction: Nursing records are part of the clinical history of the patient and give testimony of the activity that nursing provides to the patient, of their actions with him, both in the diagnosis, the treatment as well as in his evolution, supporting himself in the process of nursing care in a rational and systematic way, thereby enhancing the quality of nursing care and becoming the proof of the care provided to the patient. Objective: to analyze the internal consistency of a nursing registry model in a public hospital in the suburbs of Buenos Aires. Methods: A descriptive, cross-sectional study was carried out in the Coronary Unit of a public institution in the August-October 2021 period. The sample consisted of 64 nurses. After applying the data collection instrument in the selected sample, the construct validation was carried out by analyzing the factors and verifying the internal consistency using Cronbach's alpha. Results: The analysis of internal consistency was carried out through Cronbach's Alpha. The descriptive results with the 22 items showed a variance of each item of 3.856, a total variance of 26.816, with a Cronbach's Alpha of 0.895, showing that the instrument presents internal consistency. Conclusions: The validated Clinical Nursing Record format represents an improvement strategy to increase the quality of care. In it, information about the care provided to patients is recorded in an orderly and holistic manner.

Abstract

Background: Records are the main source of information regarding the patient's situation, and should contain complete and accurate information, as they allow retrospective evaluation of the care and attention provided. Aim: to analyze quality indicators of nursing records in a sector of the Public Hospital of the City of Oberá (Misiones) in Argentina.Methods: A retrospective, descriptive design was used for this study. The study was carried out from October 2021 to February 2022. The sampling process consisted in the selection of the patients' medical records, which finally consisted of 195 nursing records.Results: In relation to the distribution of compliance with nursing records according to the dimensions, problems are denoted in the home record, complete Kardex record (Digital Medical History System - RISMi) and complete record of nursing notes records.Conclusions: The evaluation of the quality of nursing records denoted that there are problems and weaknesses in terms of content, process and structure. The results of this study affirmed that nurses have failed to understand and apply the basic concepts of nursing diagnosis, planning, implementation and evaluation. This is alarming for the quality and effectiveness of nursing education, as well as for staff development and training programs for nurses.