Documentación de las heridas quirúrgicas en los registros de enfermería. Un estudio observacional

Resumo

Objective. To describe nursing records of surgical wounds in patients who underwent surgery in a General and Digestive Surgery Department. Methodology. Cross-sectional descriptive study. Electronic medical records of adult inpatients admitted to a General and Digestive Surgery Department who had a surgical wound during their hospital stay were reviewed. Documentation of surgical wounds in the specific wound register, nursing progress notes, care plans and continuity of care reports (nursing discharge reports) were reviewed. Results. 200 patients with a mean age of 58.24 (±17.12) years were analyzed. There were no surgical wounds documented using the specific register. However, they were documented in the nursing progress notes, with comments on wound/dressing management and wound status or assessment in 85.5% and 41% of patients, respectively. No activity on surgical wound care was scheduled in the 48% of care plans, and surgical wound assessment was not included in the 85.5% of the continuity of care reports. Discussion. Surgical wound documentation is performed in a incomplete, inconsistent and unsystematic way, without using specific structured registers. By identifying deficiencies in nursing records of surgical wounds, we would be able to suggest strategies to improve them and, therefore, to increase the quality and safety of post-surgery care