Estrategias de mejoramiento en los registros clínicos de enfermería profesional de la unidad de cuidados intensivos coronaria de la clínica San José de Cúcuta
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Fecha
2024
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Ediciones Universidad Simón Bolívar
Facultad de Administración y Negocios
Facultad de Administración y Negocios
Resumen
Enfermería es uno de los pilares dentro de la atención clínica de un paciente y los
registros clínicos son la evidencia de su actuar, por ende, esta investigación tiene como
objetivo principal proponer estrategias de mejora en el proceso de registros clínicos de
enfermería profesional de acuerdo con la normatividad vigente para el mejoramiento de
la calidad en las unidades de cuidados intensivos coronarios. Para ello se utilizó un
enfoque deductivo tipo cuantitativo, de campo no experimental y bibliográfico. Tomando
como muestra 90 historias clínicas con registros clínicos de enfermería profesional
evaluadas a través de una lista de chequeo elaborada por Elizabeth Catalina Quispe Pérez
compuesta por veintidós ítems. Como resultado se evidencio que los registros clínicos de
manera global son de regular calidad en un 67,78% y mala calidad en un 32,2% lo cual
tiene un alto porcentaje de no cumplimiento en cuanto a la normativa y fundamentación
técnico-científica de la profesión, en tal sentido estos registros se hacen de manera manual
a través de una narrativa céfalo-caudal no cumplimiento con los requisitos exigidos para
su elaboración. Se concluyó que la digitalización de los registros clínicos, la capacitación
técnico- científica de la profesión y las auditorias concurrentes de campo, son las
estrategias de mejora dentro de la seguridad y gestión del cuidado, ya que facilitan la
transmisión de la información en áreas críticas como las unidades de cuidados intensivos
coronarios, sin embargo, se deben seguir actualizando según la normatividad de cada país.
Nursing is one of the pillars within the clinical care of a patient and clinical records are the evidence of its actions, therefore, the main objective of this research is to propose improvement strategies in the process of clinical records of professional nurses according to current regulations for quality improvement in coronary intensive care units. For this purpose, a quantitative deductive, non-experimental field and bibliographic approach was used. Taking as a sample 90 clinical histories with clinical records of professional nurses evaluated through a checklist elaborated by Elizabeth Catalina Quispe Pérez composed of twenty-two items. As a result, it was found that the overall clinical records are of regular quality in 67.78% and poor quality in 32.2%, which has a high percentage of non- compliance with the regulations and technical-scientific basis of the profession, in this sense, these records are made manually through a cephalo-caudal narrative, not complying with the requirements for their elaboration. It was concluded that the digitization of clinical records, technical-scientific training of the profession and concurrent field audits are strategies for improvement in safety and care management, since they facilitate the transmission of information in critical areas such as coronary intensive care units, although they should continue to be updated according to the regulations of each country.
Nursing is one of the pillars within the clinical care of a patient and clinical records are the evidence of its actions, therefore, the main objective of this research is to propose improvement strategies in the process of clinical records of professional nurses according to current regulations for quality improvement in coronary intensive care units. For this purpose, a quantitative deductive, non-experimental field and bibliographic approach was used. Taking as a sample 90 clinical histories with clinical records of professional nurses evaluated through a checklist elaborated by Elizabeth Catalina Quispe Pérez composed of twenty-two items. As a result, it was found that the overall clinical records are of regular quality in 67.78% and poor quality in 32.2%, which has a high percentage of non- compliance with the regulations and technical-scientific basis of the profession, in this sense, these records are made manually through a cephalo-caudal narrative, not complying with the requirements for their elaboration. It was concluded that the digitization of clinical records, technical-scientific training of the profession and concurrent field audits are strategies for improvement in safety and care management, since they facilitate the transmission of information in critical areas such as coronary intensive care units, although they should continue to be updated according to the regulations of each country.
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Palabras clave
UCI, Estrategias de mejora, Registro de enfermería, SOAPIE, Plan de atención de enfermería, ICU, Nursing record, Improvement strategies, Nursing care plan
