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[Nurses attitude toward the manual recording system of medical records]. 2003

Sérgio Ribeiro dos Santos, and Adenylza Flávia Alves de Paula, and Josilene Pereira Lima
Universidade Federal da Paraíba. s.r.santos@uol.com.br

The main goal of this work was to identify factors related to nurses' understanding about the manual recording system, through a descriptive-exploratory approach, developed with two hundred nursing professionals working at different hospital institutions located in the city of João Pessoa/Paraíba, Brazil. Data were collected with special forms using the Likert's behavioral scale. Results identified five factors such as: a) lack of knowledge about information systems; b) dissatisfaction with the manual recording system; c) needs of an informatized recording system to be used in nursing care; d) desire to utilize a classification system with all steps of the nursing process; and e) difficulties with nursing diagnosis related to manual recording. Findings demonstrated the dissatisfaction of nursing professionals about the manual recording system, requiring deep changes in the established recording model.

UI MeSH Term Description Entries
D008499 Medical Records Recording of pertinent information concerning patient's illness or illnesses. Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D009733 Nursing Diagnosis Conclusions derived from the nursing assessment that establish a health status profile for the patient and from which nursing interventions may be ordered. Diagnosis, Nursing,Diagnoses, Nursing,Nursing Diagnoses
D009737 Nursing Records Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress. Records, Nursing,Nursing Record,Record, Nursing
D009741 Nursing Staff, Hospital Personnel who provide nursing service to patients in a hospital. Hospital Nursing Staff,Hospital Nursing Staffs,Nursing Staffs, Hospital,Staff, Hospital Nursing,Staffs, Hospital Nursing
D011795 Surveys and Questionnaires Collections of data obtained from voluntary subjects. The information usually takes the form of answers to questions, or suggestions. Community Survey,Nonrespondent,Questionnaire,Questionnaires,Respondent,Survey,Survey Method,Survey Methods,Surveys,Baseline Survey,Community Surveys,Methodology, Survey,Nonrespondents,Questionnaire Design,Randomized Response Technique,Repeated Rounds of Survey,Respondents,Survey Methodology,Baseline Surveys,Design, Questionnaire,Designs, Questionnaire,Methods, Survey,Questionnaire Designs,Questionnaires and Surveys,Randomized Response Techniques,Response Technique, Randomized,Response Techniques, Randomized,Survey, Baseline,Survey, Community,Surveys, Baseline,Surveys, Community,Techniques, Randomized Response
D004522 Educational Status Educational attainment or level of education of an individual. Education Level,Educational Achievement,Educational Attainment,Educational Level,Level of Education,Maternal Education Level,Maternal Educational Attainment,Maternal Educational Level,Paternal Education Level,Paternal Educational Attainment,Paternal Educational Level,Achievement, Educational,Educational Status, Maternal,Educational Status, Paternal,Maternal Educational Status,Paternal Educational Status,Status, Educational,Attainment, Educational,Attainment, Maternal Educational,Attainment, Paternal Educational,Education Level, Maternal,Education Level, Paternal,Education Levels,Educational Achievements,Educational Attainment, Maternal,Educational Attainment, Paternal,Educational Attainments,Educational Level, Maternal,Educational Level, Paternal,Educational Levels,Level, Education,Level, Educational,Level, Maternal Education,Level, Maternal Educational,Level, Paternal Education,Level, Paternal Educational,Levels, Maternal Educational,Maternal Education Levels,Maternal Educational Attainments,Maternal Educational Levels,Paternal Education Levels,Paternal Educational Attainments,Paternal Educational Levels,Status, Maternal Educational,Status, Paternal Educational
D006751 Hospital Information Systems Integrated, computer-assisted systems designed to store, manipulate, and retrieve information concerned with the administrative and clinical aspects of providing medical services within the hospital. Multi-Hospital Information Systems,Information System, Hospital,Information System, Multihospital,Information Systems, Hospital,Information Systems, Multihospital,Multihospital Information Systems,Hospital Information System,Information System, Multi-Hospital,Information Systems, Multi-Hospital,Multi Hospital Information Systems,Multi-Hospital Information System,Multihospital Information System
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000328 Adult A person having attained full growth or maturity. Adults are of 19 through 44 years of age. For a person between 19 and 24 years of age, YOUNG ADULT is available. Adults

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