Analysis of nursing records in a surgical ward of a public teaching hospital.

Abstract

This article presents a systematic descriptive and retrospective study on nursing notes on patients admitted to the surgical ward of a teaching hospital in Londrina, Paraná, Brazil, which aimed at their systematic analisys. Results show that the largest number of notes was made during the morning shift, and most of them were made by nurse auxiliaries. As to basic needs, psychobiological records were the most frequent, whereas there no psychospiritual records were found. It was concluded that nursing notes must be improved, and take into account integral care of patients