Qual o lugar da escrita sensível nos registos de enfermagem?

Abstract

The importance of nursing records know days are recognised and considered essential to ensure continuity of care, emphasizing its function of reporting the issues resulting from the process of care. Nurses believe that persons are the target of their care, and so it is imperative to build a language in which the human element is clearly visible. But does this nursing language translate sensitivity and allows us clearly to identifies persons? This question emerged as a driving force for an exploratory and descriptive study, with a qualitative approach, and requests as a main objective to know the expression of a thought act throughout the human dimension of care, in the records of the evolution of nursing writing. There was the analysis of nursing evolution notes from two customers of each of the 18 departments in a 24 hours period, according to the analysis of Bardin contents. This study concluded that nurses recognize as a major purpose for these records to ensure the continuity of care, highlighting the technical and related interventions interdependent. The emotional and family relating aspects don’t have relative expression. The categories, but with fewer units for registration, related to the attention focused on the person who is involved in the process of care, the reference to their autonomy and capacity for decision, is out on writing their individuality and the presence of the nurse in this interaction to care and be careful.