Study of nursing medical records at a hospital in inland Minas Gerais

Abstract

Objective: To study nursing records with quality analysis in medical records of a hospital in inland Minas Gerais. Methods: This documentary quantitative research collected and analyzed data from medical records of a hospital in inland Minas Gerais. The sample comprised 217 medical records of patients hospitalized between October 1 and 10, 2019. Data were submitted to simple descriptive statistical analysis. The project was approved by the Ethics Committee, in compliance with resolution 466/2012. Results: The following situations were identified: three medical records (21.4%) not checking prescriptions; 7% of medical records with incorrect terminologies, such DPP (parenteral diet) instead of NPP (parenteral nutrition); two medical records (14%) with illegible handwriting. One medical record (7%) misspelled “items”. Another one (7.1%) used correction fluid and left blank spaces. Six medical records lacked the professional's signature or stamp. Conclusion: The notes must be clear, correct, and complete and not seen as bureaucracy. Professionals must be aware of the importance of properly reported care, as medical records are also legal documents.