Knowledge and application of nursing records in the Maternity service of a regional hospital

Abstract

Introduction: Nursing records are an indispensable support for the work performed, a source of information for clinical decision-making and a legal document that reflects the actions of the health care team, so their correct knowledge and application by nursing staff is of particular relevance.

Objective: To investigate nursing staff knowledge of nursing records, as well as the quality and frequency of their application in practice.

Materials and methods: A quantitative, descriptive, cross-sectional study was conducted in the Maternity service of the Regional Hospital of Pedro Juan Caballero. Given the small population size, the entire population was included —30 nursing professionals— without sampling. A semi-structured survey was administered after hospital management authorization, and data were processed in an Excel spreadsheet.

Results: All surveyed nursing staff were female and held a bachelor's degree, with no auxiliary staff in the service. Forty-five percent reported high knowledge of filling out nursing records, 23% moderate knowledge and 32% scarce knowledge. Regarding knowledge of the legal implications of records, 55% reported scarce knowledge and 45% moderate knowledge; no professional reported high knowledge in this aspect. Eighty-two percent completed records with very high or high frequency, and 86% reported almost always complying with the continuity-of-care principle. Fifty-six percent stated that norms or protocols for filling out records exist in their service.

Conclusions: In this sample, although a relevant proportion of nursing staff reported good operational knowledge of filling out records, a marked gap was identified in knowledge of their legal implications, an area in which most professionals reported scarce knowledge, suggesting an opportunity for improvement through specific training.