Assessing the quality of records in the dressing charts, performed by nursing

65 (65%) of annotations not present in this type of tissue lesion, 85 (85%) had no type of exudate, 100 (100%) indicated no measurement of the wound and in 80 (80%), the appearance of margin and center of the lesion were not recorded. 100 (100%) of the notes were with abbreviation, 59 (59%) had no clarity of notes and 80 (80%) had grammatical errors and language of 80 (80%) contained incorrect errata and technical terminologies. 75 (75%) of nursing prescriptions were not checked and in 54 (54%) of the notes the letter was not legible.

Conclusion:

In this study the authors concluded that the quality of the ratings of nursing care are limited and inadequate.

Keywords:
Quality of Health Care; Quality Assurance; Health Care; Nursing; Bandages

Wound type	No.	%
Traumatic wounds	15	15
Pressure ulcers	51	40
Diabetic wounds	4	4
Surgical wound dehiscence	30	30
Total	*100*	*100*

Wound type	Localização anatômica
	Sacrum		Trochanter		Chest		Upper extremity		Tórax		Membro inferior		Membro superior		Total
	Nº	%	Nº	%	Nº	%	Nº	%	Nº	%	Nº	%	Nº	%	Nº	%
Traumatic wounds	-	-	-	-	-	-	15	11,36	10	7,60	5	3,80	3	2,30	33	25,06
Pressure ulcers	42	31,80	10	7,60	13	9,85	-	-	-	-	-	-	-	-	65	49,25
Diabetic wounds	-	-	-	-	-	-	-	-	-	-	4	3,00			04	3,00
Surgical wound dehiscence	-	-	-	-	-	-	18	13,60	12	10,00	-	-	-	-	30	23,60

Note-related records	Yes		No		TOTAL
Note-related records	Nº	%	Nº	%	Nº	%
Patient identification	92	92	8	8	100	100,0
Clarity of notes	41	41	59	59	100	100,0
Professional's stamp	94	94	6	6	100	100,0
Professional's signature	100	100	0	0	100	100,0
Professional's legible handwriting	62	62	48	48	100	100,0
Time at which the dressing was performed	46	46	54	54	100	100,0
Without grammatical errors	35	35	65	65	100	100,0
Correct technical terminology	20	20	80	80	100	100,0
Presence of abbreviations	0	0	100	100	100	100,0

Wound-related records			Incomplete
	No.	%	No.	%	No.	%	No.	%
Tissue type	20	20	15	15	65	65	100	100.0
Exudate type	10	10	5	5	85	85	100	100.0
Wound location	95	95	0	0	5	5	100	100.0
Bandage type	45	45	5	5	50	50	100	100.0
Wound measurement	0	0	0	0	100	100	100	100.0
Wound type	99	99	0	0	1	1	100	100.0
Pain evaluation	2	2	0	0	98	98
Appearance of wound's edge	20	20	0	0	80	80	100	100.0
Appearance of wound's center	20	20	0	0	80	80	100	100.0

Relacionado à qualidade da prescrição de enfer- magem	Sim		Não			TOTAL
Relacionado à qualidade da prescrição de enfer- magem	Nº	%	Nº		%	Nº	%
Carimbo do profissional	95	95	5	5		100	100,0
Checagem	25	25	75	75		100	100,0
Clareza da prescrição	54	54	46	46		100	100,0
Assinatura do profissional	98	98	2	2		100	100,0
Letra legível do profissional	46	46	54	54		100	100,0
Presença de abreviatura	2	2	98	98		100	100,0

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