Resumo

GUILLEN AYALA, José. Opportunity for improvement in the completion of the sheet of nursing care. Enferm. glob. [online]. 2010, n.18. ISSN 1695-6141.

The completion of the clinical assessment is the first step to begin care with good quality parameters. The involvement of nursing staff in a proper filling out of data is vital to monitor the patient; it is this that explains the initiative of our study. Objectives: • Identify the criteria on which the irregularity is immersed in the completion of the nursing assessment sheet. • Observe graphically the awareness of the improvements or lack of, in the causes identified as predisposed to irregularity in the assessment sheet. • Be able to deploy in the future an informed system for the execution of nursing care tasks from which the patient is attended. Methodology: The study sample was 30 random patients without replacement, known as a simple random sampling; previously 9 criteria were selected to reflect the perceived problems of the incorrect or non-completion of the nursing assessment in the care process. Micro sampling is made of 30 processes of care and further evaluation and re-evaluation, using as an exclusionary criterion from the process each patient who because of vital emergency is taken immediately to the intensive care unit and all patients who received a quick discharge. Sex or age are not variables. Results: The importance of a clinical follow-up of the patient becomes evident in this study, making all staff involved in the study aware, and seeing this reflected in the assessment and evaluation of the patient at the end of the process as well as the proof of human guidelines developed ethically and scientifically. Working with a nursing methodology and adequate care plans makes us aware in our study that we are working with a good continuous and coordinated follow-up. Conclusions: - Follow-up of the nursing performance protocol. - Awareness, inter-professional and professional communication of the process. - Improving the nurse assessment after involving the staff in this process once its importance has been emphasized.

Palavras-chave : Improvement; Opportunity; Nursing Sheet; Data Collection.

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