This descriptive study aimed at evaluating the quality of nursing records of surgical patients at a school hospital in the region of Northwestern Paraná State, Brazil. A retrospective audit was undertaken, based on the Systemization of Nursing Assistance as the evaluation method. One hundred thirty-four records were selected. The results showed that only the records regarding post-operation nursing prescriptions, observation of signs and symptoms, and post- operation comments could be considered complete. The annotations regarding the aspect and evolution of the skin lesions, as well as the discharge records were incomplete in 73.9% and 97% of the analyzed records. These results point to the need for education, monitoring and continuous evaluation of nursing records, aiming at their improvement and that of the rendered assistance.
Nursing records; Education, nursing, continuing; Nursing care
