Aline Tsuma Gaedke Nomura

Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

Objetivo: analisar a qualidade dos registros de enfermagem, comparando o periodo antes e depois do preparo para a acreditacao hospitalar, fazendo uso do Quality of Nursing Diagnoses, Interventions and Outcomes - Versao brasileira (Q-DIO-Versao brasileira). Metodo: estudo observacional de intervencoes realizado em um hospital universitario. Comparados os registros de enfermagem em 112 prontuarios referentes ao periodo anterior a acreditacao hospitalar e 112 ao periodo posterior, por meio do instrumento Q-DIO - Versao brasileira. Os dados foram analisados estatisticamente. Resultados: houve melhora significativa da qualidade dos registros de enfermagem. Quando avaliado o escore total do instrumento evidenciou melhora significativa em 24 dos 29 itens (82,8%). Conclusao: houve empenho a mudanca de cultura por meio das intervencoes realizadas, refletida na conquista do selo de qualidade da Joint Commission Internacional.ABSTRACT Objective: to analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation, using the Quality of Nursing Diagnoses, Interventions and Outcomes - Brazilian version (Q-DIO- Brazilian version). Method: observational study of interventions conducted in a university hospital. Nursing documentation of 112 medical records for the period before and 112 for the period after the hospital accreditation were compared using the Q-DIO instrument - Brazilian version. Data were statistically analyzed. Results: there was a significant improvement in the quality of nursing documentation. When the total score of the instrument was evaluated, a significant improvement was observed in 24 out of the 29 items (82.8%). Conclusion: there was commitment to the shift of culture by means of the interventions carried out, which resulted in the conquest of the quality seal ensured by the Joint Commission International.