Abstract

PAIVA DOS SANTOS, Silvânia et al. Evaluation of nursing records on blood transfusion in a general hospital. av.enferm. [online]. 2013, vol.31, n.1, pp.103-112. ISSN 0121-4500.

Objective: To evaluate nursing records of patients who received blood transfusion in inpatient wards of a general hospital. Methods: This was a descriptive exploratory study conducted from July to October 2009 in a large hospital in interior Minas Gerais, Brazil. Six hundred and six records of patients who underwent blood transfusion were audited. Data on 12 items were obtained from the nursing records. Results: A total of 7272 notes were reviewed. Of the evaluated items, 65% of them were in conformity with the standards. The most frequent non-conforming items were "Vital signs after blood transfusion" (83.3%), "Record of observations for the first 10 minutes of the procedure" (73.6%), "Bag number" (61.2%), "Time of completion of blood transfusion" and "Initial vital signs" (57.3%). The items recorded more correctly were "Filling in of the heading of the nursing record" (2.8%), "Stamp" (1.5%), and "Signature of the responsible nurse" (0.7%). Conclusion: Although improvements are still needed, the quality of the records was considered good because most of the nursing records on blood transfusion were in conformity with the standards.

Keywords : hemotherapy service; hematology; nursing audit; quality assurance; health care.

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