Quality of Postoperative Nursing Records

Abstract

Introduction: Nursing records are used to communicate patient information between nurses and the multidisciplinary team throughout the perioperative period. However, studies show that nurses' documentation practices are characterized by subjectivity, randomness, and poor quality.

Objective: To analyze the evidence in the scientific literature on the quality of postoperative nursing records.

Methods: Integrative literature review based on PRISMA guidelines in LILACS, PubMed, BDENF, Web of Science, Scopus and Embase databases. Articles were selected with the following descriptors: "quality of health care", "postoperative care", "nursing records". For the search strategy, the Boolean operators AND and OR were used, with joint and individual search. Inclusion criteria were to address the quality of nursing records in the title or abstract, to be a research article, and to be published in full. Gray literature and studies that did not answer the research question were excluded. Data processing and analysis was carried out using Rayyan QCRI® and Microsoft Excel® software, where articles were organized with methodological and thematic information.

Conclusion: Nursing records practices are incipient. It was clear the need for greater support from the management of health institutions in the implementation of the nursing registry concomitant to the nursing process and continuing education.