Calidad de los registros clínicos de enfermería de una Unidad de Terapia Intensiva – Neonatal

Introduction: The clinical history is a record for monitoring the assistance provided by health professionals, which has legal and professional implications and is considered the cornerstone of the hospital information system. This must meet a series of characteristics or requirements in terms of content, order, documentary standardization and legibility which, in nursing practice, allow scientific knowledge as well as clinical practice to be related.Objective: To measure the quality of the nursing records of the Neonatal Intensive Care Unit of a public institution in the City of Buenos Aires, Argentina.Method: An Observational, analytical, and cross-sectional study. 396 nursing records, selected by random sampling, were analyzed. A comparison grid was used to identify compliance with the quality requirements of the registry determined according to legal and institutional requirements.Results: A general compliance with the quality criteria of 71.95% average (minimum compliance) was found, with the priority intervention areas being the recording of nursing diagnoses and the response to nursing care. The shift and the training level showed a relationship with better general indexes in the different dimensions.Conclusions: It is expected that the results of this study can contribute to the identification of areas of intervention to improve the recording of care and activities performed by nursing professionals, while seeking to increase resources to address the issue. Introducción: La historia clínica es un registro para el seguimiento de la asistencia brindada por los profesionales de la salud, el cual tiene implicaciones legales y profesionales y es considerado la piedra angular del sistema de información hospitalario. Este ha de reunir una serie de características o requerimientos en cuanto a contenido, orden, normalización documental y legibilidad, los cuales en la práctica de la enfermería permiten relacionar los conocimientos científicos y la práctica clínica.Objetivo: Medir la calidad de los registros de enfermería de la Unidad de Terapia Intensiva – Neonatal de una institución pública de la Ciudad de Buenos Aires, Argentina.Método: Estudio observacional, analítico y transversal. Se analizaron 396 clínicos de enfermería, seleccionados por medio de muestreo aleatorio. Se utilizó una grilla de cotejo para identificar el cumplimiento de los requisitos de calidad del registro determinados según los requisitos legales e institucionales.Resultados: Se halló