Virginia Domínguez-Martínez, Departamento de Docencia e Investigación en Enfermería, Hospital General Dr. Manuel Gea González, Ciudad de México, México
Andrea Y. Molina-Vázquez, Coordinación de Servicio Social, Escuela de Enfermería del Hospital de Jesús, Ciudad de México, México
Introduction: Nursing clinical records are instruments aimed at permanently documenting the care provided, in a legal ethical framework that demonstrates the actions of nurses in relation to the care provided. Objective: To know the level of compliance with the quality of the clinical records of nurses in a second-level hospital. Method: Cross-sectional, observational, descriptive, retrospective study. Three hundred and forty-seven clinical records of patients admitted to the hospital services of the Hospital General Dr. Manuel Gea González were studied, with a hospital stay of more than 24 h and prepared on the second day after admission. Data was collected using the Cédula de Evaluación de Registros Clínicas de Enfermería (CERCE) and analyzed with descriptive statistics. The study was authorized by the Committee for Research and Ethics in Research of the institution with number 42-15-2024. Results: The percentage of global compliance of clinical nursing records was found to be 81.7%, obtaining a level of partial compliance. According to the indicators that establish the CERCE, the lowest compliance rate was evaluation and continuity of care, with a 54.9% non-compliance rate. Conclusions: The level of compliance with the quality of clinical nursing records was partial. Difficulties were identified in establishing the nursing care process in the clinical record. It is essential to establish a new nursing record format that adapts to current regulations and makes it easier for professionals to document the continuity of care provided to patients.
Keywords: Nursing records. Health status indicators. Public hospitals.