Analysis of nursing care records in the post-anesthetic recovery room

Abstract

Objective: to analyze the method of nursing registration performed in the medical record of patients admitted to the Post-Anesthetic Recovery Room of a General Hospital in the far North of Brazil. Method: Descriptive study, documentary type with a quantitative approach. Results: Of the 24 medical records analyzed, 91.66% had a care systematization form partially filled in and 8.33% did not contain the form or note of vital parameters. With legal and ethical identification, 91.67% of the medical records and 87.5% used only recognized abbreviations. 41.67% of the records were illegible and 91.67% had blank lines. Conclusion: The medical record instrument used in the operating room by nurses proved to be limited and incomplete, not complying with the Cofen guide for postoperative registration or with the recommendations of SOBECC and the Brazilian Association of Surgical/Anesthetic Recovery Nurses, showing fragility in the nursing care provided.