ANALYSIS OF NURSING RECORDS BASED ON DU GAS CATEGORIES

Abstract

The aim of this study was to analyze nursing records taken on the "Nursing Development Reports" of five randomly selected charts of patients from a Brazilian hospital. Du Gas's assumptions and the functional categories, including the whole admission process, were considered for the analysis of 3,986 records. Data were transcribed on designed instruments. Results showed that 46% of the records referred to observations concerning the patients' behaviors in relation to their health, their response to therapy and nursing care; 19% corresponded to nursing interventions required by patients' specific needs; 17% reflected the performance of routine actives and 15% described the execution of medical prescriptions. We point out that the study revealed simple, incomplete and repetitive records, which did not allow an objective evaluation of the patient's health-disease process.