Paper
Sunday, November 13, 2005
Evaluation of the Implantation of the Nursing Record in the Hygia Emergency Care Card: Possibilities to Improve Care Systemization With a Focus on User Needs
Ione Carvalho Pinto, RN, PhD1, Pedro Fredemir Palha, RN, PhD2, Ivana Astolphi Gandra Passeri, RN3, Leila Aparecida de Castro, RN4, and Andrea Regina Leonardo Calderero Azzenari, RN4. (1) Department of Maternal-Infant Nursing and Public Health, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto-SP, São Paulo, Brazil, (2) Department of Maternal-Infant Nursing and Public Health, Faculty Member in the Department of Maternal-Infant Nursing and Public Health of the University of São Paulo at Ribeirão Preto C, Ribeirão Preto, São Paulo, Brazil, (3) Department of Maternal Infant and Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil, (4) Nurse of Emergency Care at School Health Center, University of São Paulo at Ribeirão Preto Medical School - CSE-FMRP-USP, Ribeirão Preto, São Paulo, Brazil
| Learning Objective #1: Discuss the implantation of the nursing record at an emergency care service in Brazil |
| Learning Objective #2: Describe the nursing record and its aim at an emergency care service in Brazil |
This study evaluated nursing records at an Emergency Service in Ribeirão Preto - Brazil. We analyzed the Hygia Cards for user care produced from November 1st to 30th 2004. In August 2004, guidelines were elaborated, involving the nursing team and students from a local nursing college to implant the Nursing Record in the Hygia Emergency Care Card, in order to allow for user identification through a stamp with information, so as to organize care and nursing records with a focus on user needs. In September 2004, the nursing record was implanted in the Hygia Card. In October 2004, the trained nursing team was evaluated to identify the possibilities and difficulties linked up with the operationalization of this record. We evaluated all Cards for November and identified that 450 (7%) out of 5946 contained the nursing record. We decided to review 25% (114) of the Cards containing the nursing record and evaluated that 21% were considered as urgency, with heart problems and arterial hypertension as the main causes. 50% of the urgencies were women and 50% were men between 40 and 69 years old. None of the records contained any analysis of the vaccine situation, while 70% did not give any information on personal antecedents. 78% of the Cards did not contain any records on follow-up at a Basic Health Unit. As to user needs, in 92% of the Cards, the nursing record was coherent with the medical appointment. 82% of users were in the productive age range. The nursing team is able to register the necessary information on the Hygia card, thus facilitating the reorganization of the care user flow, identifying users' needs, changing the logic of assistance by order of arrival, listening to patients, applying nursing knowledge in practice and producing data on the population that attends the service.