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Pedreira-Robles G, Herrera-Morales C, Vasco-Gómez A, Martínez-Delgado Y, Junyent-Iglesias E. Efectividad de una intervención sobre el registro de la valoración enfermera al ingreso. Metas Enferm jul/ago 2021; 24(6):49-56. Doi: https://doi.org/10.35667/MetasEnf. 2021.24.1003081778
Guillermo Pedreira-Robles1, Cristina Herrera-Morales1, Ana Vasco-Gómez1, Yaiza Martínez-Delgado1, Ernestina Junyent-Iglesias1
1Máster. Servicio de Nefrología. Hospital del Mar. Parc de Salut Mar. Barcelona
Guillermo Pedreira Robles. Servicio de Nefrología del Hospital del Mar de Barcelona. Passeig Marítim, 25-29. 08003 Barcelona.
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Objective: to assess the efficacy of an intervention on compliance with the nursing assessment interview at admission.
Method: an analytical, quasi-experimental, pre-post study on a single arm at the Hospital del Mar of Barcelona. The primary variable of interest was the level of compliance, collected according to the Functional Health Patterns Model by Marjory Gordon. There was an analysis of 60 clinical records before the intervention, and 60 after the intervention. The intervention consisted in a training session, where the results of the first analysis were shared, and the theoretical basis of the Nursing Care Process was addressed, as well as the importance of its compliance. A descriptive analysis was conducted with absolute and relative frequencies, and percentage differences were calculated for the analysis of efficacy.
Results: the completion of clinical record at admission increased from 66.9% to 74.5% after the intervention. In the assessment by patterns, there was an increase from 64.9% to 75,7%, though patterns 6 (Cognitive/perceptive) and 11 (Values/beliefs) reduced their level of compliance. The same occurred with the items for personal background and the Observations section. However, there was an increase in the level of compliance with signing the report, from 96.7% to 98.3%, and in the care path assignment, from 95.0% to 100%, which was the only one which increased up to total compliance.
Conclusions: the intervention was effective in an overall way, increasing the level of compliance with clinical record at admission, although not in all items or patterns.
Nursing assessment; medical records; Nursing staff at hospital; Nursing Care ProcessFunctional Health Patterns
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