Nivel de cumplimiento de la Norma Oficial Mexicana 168-SSA1-1998 del expediente clínico, por el personal de Enfermería en un Instituto Nacional de Salud

Introduction. It is essential to the registration of nursing provides daily care to patients, both to give adequate sanitary quality for the development of the profession. Therefore, professionals must know not only the proper implementation of the records, but also the current legislation that affects the user and the same health care provider. Material and methods. We performed a descriptive, observational, and correlational, with a stratified sample of 375 cases, was applied an assessment tool based on the aspects that makes the NOM-168-SSA1-1998 for the preparation of medical records. Results. Was identified that the level of performance for the development of clinical nursing records is 5% is inadequate, 44% and 51% Regular Sound. The present orthopedic service 25% for the category of inappropriate, 23% for regular neurosciences and oncology with 27% for Sound. The parametric test ANOVA made in the variables of performance and service level howed that if there is a difference with an F of 0.62, in the suitable filling of the registries of infirmary according to the Official Norm, in the different survey services. Conclusions. Compliance with the regulations for the production of the records kept by the nurse, indicates the need to increase efforts to ensure quality records in order to achieve its goal of being an instrument of communication in relation to the patient without put aside their ethical and legal features, as they found a high incidence of failure to register the name and signature of who develops, in the same vein it was found that the documents contain deletions, erasures and illegibility, on the other side are omitted Data regarding the external habitus, and the route of administration of drugs, which directly affects patient safety. Introducción. Es esencial hacer el registro de los cuidados que enfermería proporciona diariamente a los pacientes, tanto como elemento necesario para dar una adecuada calidad sanitaria como para el desarrollo de la profesión. Por ello, los profesionales deben conocer la NOM-168-SSA1-1998 Del Expediente Clínico y demás legislación vigente del permita el adecuado cumplimiento de los registros y de la práctica profesional de enfermería. Material y métodos. Se realizó un estudio descriptivo, transversal, observacional y correlacional, con una muestra estratificada de 375 expedientes clínicos, utilizando un instrumento de valoración basado en la NOM- 168, el cual se aplicó en diferentes servicios de un institut