Quality of the electronic nursing records of a highly complex hospital in the city of Corrientes. Year 2021.
DOI:
https://doi.org/10.59843/2618-3692.v24.n42.42639Keywords:
quality of health technology, electronic health record, information managementAbstract
Introduction: recording the care that nursing provides daily to patients is an essential task, both for providing adequate health quality and for the development of the profession. Objective: the objective was to identify the quality of the electronic nursing records of a highly complex hospital in the city of Corrientes. Methodology: a cross-sectional descriptive quantitative study was carried out where 133 digital medical records were reviewed using an adapted and previously validated tool. Results: specifically, the patient identification variable obtained good quality, regarding the assessment record, it was identified that 92% of the medical records registered less than 6 indicators, a poor quality, and the remaining 8% registered regular quality, and the variable interventions obtained a poor quality with 87% registering the indicators. Conclusion: in the results of the investigation, it was concluded that the quality of the electronic nursing records of the hospital's intensive care service is of poor quality compared to the electronic record of the nursing process.
Downloads
References
1. Cancela A., Fontán V., Martins A., Piriz Y., Vittola M. Características de los registros del personal de enfermería en la historia clínica en cuanto a su salud [Internet] [TIF]. [Montevideo]: Universidad de la República; 2010 [cited 2023 Mar 21]. Available from: https://www.bvsenf.org.uy/local/tesis/2010/FE-0345TG.pdf
2. Maetos-García M.D. Metodología enfermera y sistemas estandarizados de lenguaje enfermero en la historia clínica digital [Internet] [Tesis]. [Sevilla]: Universidad de Sevilla; 2017 [cited 2023 Mar 21]. Available from: https://idus.us.es/bitstream/handle/11441/69103/Tesis%20Doctoral%20Maria%20Dolores%20Mateos%20 Garcia.pdf?sequence=1&isAllowed=y
3. García-Ramírez S., María A., Marco N., Morganizo L.V. Normas básicas para la elaboración de los registros de enfermería. Nure Investigación [Internet]. 2007 [cited 2023 Mar 21];(8). Available from: https://www.nureinvestigacion.es/OJS/index.php/nure/article/view/335/326
4. Chávez-CruzAL, Molina-Regalado J.L. Evaluación de la calidad de la atención en salud mediante el modelo de Avedis Donabedian, en el área de Emergencia del Hospital Paravida, de julio a diciembre 2014 [Internet]. [San Salvador]: Universidad del Salvador; 2015 [cited 2023 Mar 22]. Available from: https://ri.ues.edu.sv/id/ eprint/11055/1/Tesis%20Final.pdf
5. Gómez F., Mezzi de Tonsich R.M., et al. El proceso enfermero. Propuesta para orientar la enseñanza y la práctica en enfermería. In 2020. p. 60–2.
6. Torres-Gómez D. Indicadores de evaluación de los registros clínicos de enfermería: Implementación de una herramienta tecnológica. Horizonte Sanitario [Internet]. 2021 Jul 3 [cited 2023 Mar. 21];20(3):315–28. Available from: https://dialnet.unirioja.es/descarga/articulo/8441805.pdf
7. López-Cocotle J., Saavedra-Vélez C., Moreno-Monsiváis M. Niveles de cumplimiento de calidad delos registros clínicos de enfermería. Revista Electrónica Medicina, Salud y Sociedad [Internet]. 2015;6(1):65–7. Available from: https:// www.researchgate.net publication/318967258Nivelesdecumplimientodecalidaddelregistroclínicodeenfermería
8. Quevedo-Ríos G.D. Evaluación de la calidad de los registros de enfermería en el área de Trauma Shock del servicio de Emergencia. Hospital Regional Lambayeuqe 2015 [Internet] [Tesis]. [Chiclano]: Universidad Católica Santo Toribio de Mogrovejo; 2015 [cited 2023 Mar 21]. Available from: https://tesis.usat.edu.pe/ bitstream/20.500.12423/1359/1/TM_QuevedoRiosGuilliana.pdf
9. Arpí L., Panattieri N.D., Godio C.G., Paz V.S., Dackiewicz N. Diagnóstico de situación de seguridad del paciente en Argentina. Estudio transversal. Arch Argent Pediatr [Internet]. 2017 Feb. 1 [cited 2023 Mar. 21];115(1):82–8. Available from: http://www.scielo.org.ar/pdf/aap/v115n1/v115n1a27.pdf
10. Giraudo P. Evaluación de la calidad de los registros de enfermería en el sector de Terapia Intensiva en el Hospital San Vicente de Paul de Villa del Rosario [Internet]. 2015 [cited 2023 Mar 21]. Available from: http:// lildbi.fcm.unc.edu.ar/lildbi/tesis/Giraudo-patricia-del-valle.pdf
11. Martínez-Castillo A. Actualización de los diagnósticos enfermeros en los registros informáticos del Servicio Andaluz de Salud. Revista Científica de Enfermería [Internet]. 2018 Dec 21 [cited 2023 Mar 21];(16):18. Available from: https://rua.ua.es/dspace/bitstream/10045/85234/1/RECIEN_16_03.pdf
12. Oliveira N.B., Peres HHC. Calidad de la documentación del proceso de enfermería en sistemas de apoyo a la decisión clínica. Rev. Lat. Am. Enfermagem [Internet]. 2021 [cited 2023 Mar 19]; 29:1–12. Available from: https://www.scielo.br/j/rlae/a/cM8W9ZQktJFsKNJQFSHzW6m/?lang=es&format=pdf
13. Huasaja Vásquez J.L., Huasaja Vásquez L.S. Calidad de los registros de enfermería en el servicio de emergencia de adultos del Hospital San Juan de Lurigancho. 2018 [Internet] [Tesis]. [Lima]: Universidad María Auxiliadora; 2019 [cited 2023 Mar 21]. Available from: https://repositorio.uma.edu.pe/bitstream/ handle/20.500.12970/185/26-2019%20%28Final%29.pdf?sequence=1&isAllowed=y
Downloads
Published
Issue
Section
License
Copyright (c) 2023 Sanatorio Allende
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Those authors who have published with this journal, accept the following terms:
- Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
- NonCommercial — You may not use the material for commercial purposes.
