Avaliação dos registros de enfermagem em prontuários: uma revisão de literatura

Abstract

The records in the patient's medical records are of great importance because it is a document which must have authenticity and reliability. The study aims to analyze the scientific production about the importance of achieving the nursing records in the several health services. This is an exploratory literature review of research with qualitative approach, it was carried out through articles available in electronic data published in the period from 2011 to 2016. We searched the following health care databases: BVS (Library Virtual Health), LILACS (Latin American and Caribbean Health Sciences), SCIELO (Scientific Electronic Library Online) and BDENF (bibliographic database in nursing area). Were used the following inclusion criteria for the studies that have integrated research: articles that addressed the proposed theme, published from 2011 to 2016. The exclusion criteria consisted in repeated articles, studies that do not contemplate the theme proposed. The results of the analyzes presented in this article demonstrate lack of nursing professionals to perform the notes in the medical record with relevant information that meets the ethical-legal requirements. Therefore we conclude that the study expands knowledge of nursing professionals in regard to nursing records, giving relevance and value to the act of keeping a constant communication among all professionals involved in the care provided.