Os registros de enfermagem como ferramenta para a gerência do cuidado

Abstract

The study was characterized by the descriptive type, of a comprehensive nature and with a qualitative approach. The objective was to understand how nursing records were used by nurses for care management; characterize the types of nursing records used by nurses for care management; to learn how nurses used nursing records for care management; to know the factors that facilitated and made difficult the use of the nursing records for the management of the care; discuss the intervening aspects for the use of nursing records for the management of care. Data were collected in the Medical Clinic of a public teaching hospital, after approval by the Research Ethics Committee of the referred institution, under the number 2213143. Participated in this study 13 nurses who were in the care management. For data collection, the following techniques were used: semi-structured interview, participant observation and documentary research. Initially, semi-structured interviews were carried out between October and November 2017, which combined closed and open questions. The IRaMuTeQ 0.7 alpha 2 software was used to make the interviews operational. After the interviews were completed, the participant observation stage was performed, after the participants' discourse analysis. This technique was developed on 21 occasions during the daytime service, with 150 hours of observation, whose contents were recorded in field / observation notes. Concomitant to the participant observation was the documental research stage, which was based on a script of analysis of medical records and databases, books, forms and nursing requirements. As results, three categories emerged: nursing records as a means of communication; instruments adopted in the elaboration of nursing records and; the context of utilization of nursing records and the development of care management. It was noticed that many nurses saw the nursing records as being only part of the nursing management, dissociating it from the nursing care itself. It was concluded that nursing records contribute to the management and care, and these two dimensions are articulated, conjugated and closely intertwined. Although, in practice, the nursing record does not also configure as a basic tool of communication between the health and parameter practitioners to prove the quality of the patient care.