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Revista Cuidarte

versão impressa ISSN 2216-0973

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HERNANDEZ-LOPEZ, Gloria Isabel. History of Nursing: an Instrument Learning and much more. Rev Cuid [online]. 2011, vol.2, n.1, pp.240-242. ISSN 2216-0973.  http://dx.doi.org/10.15649/cuidarte.v2i1.64.

Introduction: This article show a document entitled Nursing Medical Record (HCE), which acts as an instrument and teaching-learning strategy, teaching in clinical practice for the care discipline. To do this all the knowledge of the area, its epistemology and scientific thinking are combined providing quality regulations requiring documentation of modern society.Materials and Methods: The reflection article presents a document (HCE) which acts as a learning tool, whose aim is to link academic theory with clinical practice. Is elaborated each day of the rotation, where a patient is assigned to the student, pretending that executing it by 50% during the same turn and the rest and the rest, doing bibliographic research. It has a flexible model, designed by contributions of contemporary education. It is a checklist format that includes key words and symbols that makes manual or electronic registration easier. Is guided for the teacher and developed by the student, together using the techniques of physical assessment, organizes data and detects the. The scheme forces to question orderly; lay up, retrieve, manage, encode to the nursing diagnosis, research and design an appropriate care plan, also to evaluate, developping a critical thinking and a self-regulated learning.The Instrument (HCE) basically has the institutional head, patient identification, anamnesis, tables of: vital signs, fluid control, medications received, the risk weight. Tables for: cephalo-caudal valoration of test results, the description of the pathology, the situation analysis of care, nursing diagnoses and nursing notes. Results: You see how the student elaborate the instrument (HCE) and physical valoration, faster and faster through the rotation. The assessment is reflected in the institutional clinical history, supported by the signature of the teacher. In the bibliographic review of the theme, can be observe the appropriation and auto management of the student learning. Discussion and Conclusions: Is a flexible instrument (HCE) that allows according to specialty, get variants that facilitate learning and take direction the practice, highlighting the process. Is the starting point for teaching and autoregulation learning.

Palavras-chave : Clinical History; Assessment; Nursing Diagnosis; Caring Plan.

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