Analysis of records by nursing technicians and nurses in medical records / Análisis de los registros médicos de técnicos de enfermería y de enfermeros / Análise dos registros de técnicos de enfermagem e enfermeiros em prontuários

ABSTRACT Objectives: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. Methods: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records. Results: the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses' records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%. Conclusions: the study showed that nursing professionals perform their records incompletely and often do not document the care provided.

RESUMEN Objetivos: evaluar las no conformidades principales de los registros de enfermería de un hospital público del Nordeste en la ciudad de Natal (Brasil). Métodos: estudio descriptivo, transversal, de enfoque cuantitativo. Se llevó a cabo en enfermerías médicas y quirúrgicas. La muestra constó de 120 registros médicos de pacientes hospitalizados entre octubre y diciembre de 2016. Los datos obtenidos fueron tabulados y analizados por estadística simple en frecuencias absoluta y relativa con el software Microsoft Excel 2013. Se utilizó el Diagrama de Pareto en la evaluación de las no conformidades de los registros. Resultados: entre los principales problemas en los registros de enfermería, se destacó la ausencia de la categoría profesional y del número de la comisión, responsables de un 41,8% de las no conformidades en los registros de técnicos de enfermería, mientras que en las anotaciones de los enfermeros se sobresalió la ausencia de hora y caligrafía ilegible, con un 61,2%. Conclusiones: el estudio demostró que los profesionales de enfermería hacen sus registros de forma incompleta y que muchas veces no documentan el cuidado ofertado.

RESUMO Objetivos: analisar as principais não conformidades dos registros de enfermagem de um hospital público do Nordeste na cidade de Natal. Métodos: estudo descritivo, transversal, abordagem quantitativa. Realizado em enfermarias médicas e cirúrgicas. Amostra composta de 120 prontuários de pacientes internados entre outubro e dezembro de 2016. Os dados obtidos foram tabulados e analisados por estatística simples em frequência absoluta e relativa com o software Microsoft Excel 2013. Para avaliar as não conformidades dos registros, usou-se o Diagrama de Pareto. Resultados: como principais problemas nos registros de enfermagem, destacou-se a ausência da categoria profissional e número do conselho, responsáveis por 41,8% das não conformidades nos registros de técnicos de enfermagem, enquanto nas anotações dos enfermeiros foram a ausência de hora e as letras ilegíveis, com 61,2%. Conclusões: o estudo evidenciou que os profissionais de enfermagem realizam seus registros de forma incompleta e que muitas vezes não documentam o cuidado prestado.

Strategies to improve the performance of female health workers in West Bengal: A cross-sectional survey.

Background. Female health workers in India face an increasing workload that affects their performance. We did a study in 2 districts of West Bengal, India, to quantify their workload and identify determinants of good performance. Methods. We randomly sampled female health workers from the health department’s list. First, we quantified the time allocated to tasks through observations of work sessions. Second, we estimated the prevalence ratio (PR) of aboveaverage performance for three indicators (DPT-booster coverage, antenatal check-up coverage and family planning performance) according to selected potential determinants. Results. Female health workers spent 26% of their time in documentation. We recruited 42 female health workers (average population covered: 6495). Larger floor space (PR 2.5; 95% CI 1.2–5.3), use of simplified documentation procedures (PR 2.5; 95% CI 1.2–5.2) and monthly supervision (PR 3.0; 95% CI 1.1–8.5) were associated with above-average DPT-booster coverage. Availability of a private space was associated with above-average coverage in antenatal check-up (PR 1.9; 95% CI 1.0–3.5) and family planning (PR 2.5; 95% CI 1.2–5.2). Workers who used existing resources to cope with multi-tasking performed better. Conclusion. Female health workers spent excessive time in documentation which left less time for service delivery. Infrastructure, planning and supervision affected performance and these areas must be strengthened to improve primary healthcare services.

Análise da produção científica sobre documentações fotográficas de feridas em enfermagem: [revisão] / Analysis of scientific literature on photographic documentation of wounds in nursing: [review] / Análisis de la producción científica de la documentación fotográfica de las lesiones en la enfermería: [revisión]

Fotografia de feridas foi incorporada às práticas de saúde como instrumento para auxiliar profissionais na observação, evolução e registro claro e preciso das lesões e tecidos adjacentes. Este estudo objetivou identificar produções científicas, nacionais e internacionais, sobre documentação fotográfica de feridas em enfermagem, publicadas no período de 1996 a 2007. Foram encontrados 124 artigos publicados, referente ao tema nos seguintes bancos de dados: MedLine 80 (64,5%), OVID 43 (34,6%) e LILACS 1 (0,8%). Após leitura dos artigos fizeram parte deste estudo 43 (34,7%) publicações. Destes artigos analisados, os países que apresentaram publicações, foram: Estados Unidos 18 (41,8%), Reino Unido 16 (37,2%), Austrália 6 (13,9%) e países como Canadá, Holanda e Brasil apresentaram respectivamente 1 (2,3%) artigo cada. Foram estabelecidas quatro categorias referentes às abordagens dos artigos: aplicação prática da fotografia de feridas 25 (58,1%), aplicação de fotografia em programas de computador 7 (16,2%); recomendações técnicas para fotografar feridas 6 (13,9%) e avaliação da prática de fotografar feridas 5 (11,6%). Os artigos analisados mostraram que a prática de fotografar feridas fornece subsídios para a tomada de decisão dos profissionais de enfermagem, minimizando o tempo e os custos de tratamento, bem como o sofrimento do paciente.

The photograph of wounds was incorporated into health care practices to assist professionals in observation, evolution and clear/ accurate record of injury and adjacent tissue. This study aimed to identify scientific productions, national and international, on a photographic documentation of wounds in nursing, published from 1996 to 2007. In this paper were found 124 published articles concerning the issue in the following databases: MEDLINE 80 (64,5%), OVID 43 (34.6%) and LILACS 1 (0.8%). After careful reading of this articles were chosen 43 (34.7%) publications. These articles reviewed, the countries that presented publications on this issue were: the United States 18 (41.8%), United Kingdom 16 (37.2%), Australia 6 (13.9%) and countries like Canada, Holland and Brazil had 1 (2.3%) respectively. Have been established four categories: practical application of the photograph of wounds 25 (58.1%), application of photography in programs for computer 7 (16.2%); technical recommendations to photograph wounds 6 (13.9%), and evaluation of the practice to photograph wounds 5 (11.6%). The examined showed articles that the practice to photograph wounds provides subsidies for a decision of the professionals in nursing and aiming to minimize the time and cost for treatment of wounds and the patient's suffering.

Fotograbar heridas se incorporó a las prácticas de cuidado de la salud como una herramienta para ayudar a los profesionales la observación, evolución y registro claro y preciso de las lesiones y de los tejidos adyacentes. Ese estudio tuvo como objetivo identificar las producciones científicas, nacionales e internacionales, acerca de documentación fotográfica de las heridas en la enfermería, publicado en el período de 1996 a 2007. Ellos se encontraron 124 artículos publicados en relación con la cuestión en las siguientes bases de datos: MEDLINE 80 (64,5%), OVID 43 (34,6%) y LILACS 1 (0,8%). Después de una cuidadosa lectura de los artículos que forman parte de este estudio, sólo 43 (34,7%) publicaciones. De estos artículos revisados, los países que presentan las publicaciones fueron: los Estados Unidos 18 (41,8%), Reino Unido, 16 (37,2%), Australia 6 (13,9%) y de países como Canadá, Holanda y Brasil han respectivamente 1 (2,3%) cada uno de los artículos. Ellos se establecieron cuatro categorías: aplicación práctica de fotografía de heridas 25 (58,1%), la aplicación de fotografía en los programas de ordenador 7 (16,2%); Recomendaciones técnicas de fotografía heridas 6 (13,9%), y la evaluación de la práctica de hacer fotografías de heridas 5 (11,6%). Los artículos examinados mostraron que la práctica de hacer fotografías de heridas proporciona subsidios para una decisión de los profesionales de enfermería y reduciendo al mínimo el tiempo del tratamiento e costos, sí como el sufrimiento del paciente.

Needle sticks injury among nurses involved in patient care: a study in two medical college hospitals of West Bengal.

A hospital-based retrospective study on a sample of 228 nurses involved in patient care, in two medical college hospitals of West Bengal, showed that 61.4% of them sustained at least one Needle Stick Injury (NSI) in last 12 months. The risk of such injuries per 1000 nurses per year was found to be 3,280. Out of the most recent injuries among 140 nurses, 92.9% remained unreported to appropriate authorities; in 52.9% events hand gloves were worn by the nurses; only 5% of those nurses received hepatitis B vaccine, 2.1% hepatitis B immunoglobulin and none of them received post exposure prophylaxis for HIV.

Evaluation of the impact of the Kuwait diabetes care program on the quality of diabetes care

To evaluate the impact of the Kuwait Diabetes Care Program on the quality of care provided for diabetic patients in the Primary Health Care setting. The Kuwait Diabetes Care Program developed, published and disseminated clinical practice guidelines, conducted training courses, standards for diabetes care, and introduced a monitoring and evaluation system. Four audits [September 1999, October 2001, 2002 and 2003] were carried out at five diabetic clinics. September 1999 referred to in this study as first [baseline] audit was prior to the introduction of the clinical practice guidelines. The three other audits were performed to assess adherence with the guidelines in the administrative management of patients' records and implementation of the standards. Two hundred and fifty patients were involved in the study. The proportion of patients with organized, structured files increased significantly from 60.0 to 100.0% [p < 0.001], and recording of patients' demographic data increased from 38.6 to 95.6% [p < 0.001]. Use of structured visit sheets, proper fixation of the laboratory and prescription sheets had also improved significantly. The prevalence of smoking assessment, fundus examination, and foot examination increased significantly from 2.8 to 27.2% [p < 0.001]; 2.4 to 31.6% [p < 0.001]; 0.4 to 40.4% [p < 0.001], respectively. The prevalence of measuring urinary microalbumin, serum creatinine and HbAlc increased significantly from 4.4 to 26.4% [p < 0.001]; 16.0 to 78.4% [p < 0.001], and 10.4 to 60.8% [p < 0.001], respectively. The prevalence of measuring serum total cholesterol, triglycerides, HDL-C, and LDL-C levels increased significantly from 16.4 to 80.0% [p < 0.001]; 14.4 to 80.0% [p < 0.001]; 2.4 to 32.8% [p < 0.001], and 2.4 to 24.0% [p < 0.001], respectively. This audit shows that a national diabetes program was associated with improved processes of diabetes care. Further, support from health authorities, provision of manpower resources, a continuing monitoring and evaluation system, and conduction of structured education programs may lead to further improvements in the quality of diabetes care

Producción de artículos científicos sobre salud en seis países de América Latina, 1973 a 1992 / Production of scientific articles about health in six Latin American countries, 1973-1992

Con objeto de observar las tendencias de la investigación sobre salud en América Latina, se analizó la producción de artículos resultantes de investigaciones biomédicas, clínicas y de salud pública originadas en Argentina, Brasil, Chile, Cuba, México y Venezuela de 1973 a 1992, inclusive. De la base de datos del Institute for Scientific Information (ISI), se recuperaron 41 238 artículos con primeros autores residentes en esos países. Esta producción se analizó por área de estudio, tipo de investigación, país, número de autores e instituciones que participaron en la investigación, y citaciones recibidas por cada artículo. Se hizo también un análisis de 95 artículos en epidemiología seleccionados de 570 publicados por autores de los seis países en 11 revistas de salud pública de gran prestigio internacional. Los resultados muestran que el número de trabajos publicados aumentó 117% entre el primero y último quinquenios. La investigación clínica tuvo la distribución más homogénea entre los países y la de salud pública, la más concentrada (60,7% se originó en el Brasil). Los artículos de investigación biomédica y de salud pública tuvieron un crecimiento relativamente mayor que los de investigación clínica a lo largo del período. Se observó una disminución relativa de artículos de un solo autor ­lo que sugiere trabajo en equipo más frecuente­ y unaumento de artículos con autores vinculados a dos o más instituciones nacionales o extranjeras, lo cual indica mayor cooperación entre instituciones y países. El promedio de citacionesrecibidas por artículo fue 3, lo que corresponde a menos de la mitad de las que reciben los artículos de la base del ISI (7,78). En cuanto al subconjunto de los 95 artículos de epidemiología,la gran mayoría (96%) trataban de enfermedades infecciosas o del área maternoinfantil, mientras que en la literatura internacional 78% de los artículos estaban dedicados a las enfermedades crónicas. En este conjunto se observó más cooperación con instituciones extranjeras y un índice de 4,36 citaciones por artículo.Se concluye que, pese a las limitaciones inherentes a este tipo de estudio, se pudieron notar algunas tendencias generales del desarrollo de la investigación en los seis países con mayor producción científica de América Latina y formular hipótesis sobre los factores que determinan esas tendencias. Tomados con cautela, los resultados de estudios de este tipo pueden ser de gran valor al definir políticas de ciencia y tecnología en salud

The production of articles resulting from biomedical, clinical, and public health studies that originated in Argentina, Brazil, Chile, Cuba, Mexico, and Venezuela from 1973 through 1992 was analyzed to discover trends in health research in Latin America. From the database of the Institute for Scientific Information (ISI), 41 238 articles with first authors who resided in those countries were extracted. These articles were analyzed by subject area, type of study, country, number of authors and institutions that participated in the investigation, and citations received by each article. Also analyzed were 95 articles in epidemiology selected from a pool of 570 published by authors from the six countries in 11 public health journals that enjoy international prestige. The results showed that the number of published works increased by 117% between the first and last five-year periods within the study period. Clinical research was distributed the most evenly among the countries, and public health research was the most concentrated (60.7% originated in Brazil). The numbers of biomedical and public health research articles showed relatively more growth than those reporting on clinical research throughout the period. A relative decrease was found in articles by only one author, which suggests a greater frequency of team efforts, and an increase was seen in articles with authors tied to two or more national or foreign institutions, which indicates greater cooperation between institutions and countries. The average number of citations received by each article was 3, which was less than half the number received by the articles in the ISI database (7.78). Regarding the subset of 95 articles in epidemiology, the great majority (96%) dealt with infectious diseases or maternal and child health, while in the international literature 78% of such articles were about chronic diseases. This group of articles gave evidence of more cooperation with international institutions and had a citation index of 4.36 per article. It is concluded that, despite the inherent limitations, this type of study reveals some general trends in the development of research in the six Latin American countries with the greatest scientific production and makes it possible to formulate hypotheses on the factors that influence these trends. Taken with the proper caution, the results of studies like this one can be of great value in defining health science and technology policies