[Evaluation of nursing records on the physical examination]. / Avaliação dos registros de enfermagem quanto ao exame físico.

ABSTRACT

The nursing records are essential to generate benefits to individualized care planning, once data collection is the first step of the Nursing Process. The purpose of this study is to analyze the records made by nurses during each physical patient examination in critical care units (CCU) and hospitalization units (HU). This is a transverse and retrospective study, in which forms and records from both public and private hospitals were analyzed. From the 69 records considered, we observed a greater quality and frequency in records from CCUs, while records from HUs were mostly about intercurrences that happened during the shift. The research shows a deficit in physical examination records of patients, which complicates the individual assistance focused on the real needs of the patient, since many changes in patient's condition might not be recorded.