Nursing Documentation in Occupational Health

摘要

Purpose: Traditionally, nursing documentation has been consistent with hospital standards and legal definitions of clinical nursing practice. Identify data and information nurses need to be recorded in order to maintain the continuity and quality of nursing care and the efficiency of nursing performance is a research question that is moving professionals around the world. This study objective is to describe the analysis of nursing documentation in the patient records. Methods: It is a retrospective study. The study was conducted in the ambulatory occupational health nursing; it was selected 111 patient records. Of these, in 106 we identified a total of 775 nursing records. The nursing records comprise the following dimension: identification, job history, health state, health and safety, psychological e socio-cultural, medical history, physical examination and nursing assessment. Results: In the data set elements found as documented in the subjective data and objective data, there was higher frequency of data elements related to the following nursing dimensions: health state, health and safety, physical examination and nursing assessment. The dimension of job history we found that 25% of the nursing records did not documented information about the current work status of the patient. In addition, the current job activity (20.77% of the records), working day (9.03% of the records), job process (8.13% of the records), worksite exposure (8.0% of the records), environmental works (6.19% of the records), occupation (5.81% of the records), job time (4.39% of the records), before job activity (4.13 % of the records), and work location (3.23% of the records) were not also documented. Conclusion: In conclusion, the present study was an attempt to highlight the importance of data to be documented and organized in the existing information systems in the specific area of occupational health care. The adequate data collected can provide the right information to improve nursing care in this care setting and enhance health population.