Abstract

BAUTISTA RODRIGUEZ, Luz Marina et al. GRADE OF ADHERENCE TO THE PROTOCOL OF CLINICAL NURSING RECORDS. Rev Cuid [online]. 2016, vol.7, n.1, pp.1195-1203. ISSN 2216-0973.  https://doi.org/10.15649/cuidarte.v7i1.237.

Introduction: The use of the guides of management clinics, protocols, and manuals are an essential element in the delivery of health services with quality. The Protocol of clinical records is a tool that guides the nursing staff in the key guidelines that should be considered in each of the care given. Materials and Methods: A quantitative cross-sectional descriptive study was conducted. The sample was conformed by 105 nursing assistants and 15 nurses working in a health institution of IV level of complexity, for the collection of the information was used a checklist and knowledge test protocol based on the records of the institution. Results: The level of knowledge of the staff professional and auxiliary nursing on the protocol is good with a 61%, followed by a regular level of knowledge with 29%. The applicability is good by 14% and 54% of the staff professional and auxiliary nursing has bad applicability to the protocol, finding that is not completely file formats that are included in the medical history. The level of adherence is good for 30% of the staff professional and auxiliary nursing. Discussion and Conclusions: We found that the nursing staff have a good level knowledge only in the clinical records that use frequently; however the nursing staff not to apply this knowledge in their daily practice, evidenced by 54% of bad applicability.

Keywords : Protocols; Knowledge; Nursing; Electronic Health Records.

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